AND ASSISTED SUICIDE
Mollie Dunsmuir, Margaret Smith, Susan Alter, Law and Government Division
Sandra Harder, Political and Social Affairs Division
Revised 12 August 1998
A. Historical Background
B. Policy Considerations
1. Chronic and Incurable Diseases
Health Care Costs and an Aging Population
C. Canadian Law
1. The Criminal
Code and Euthanasia
The British Columbia Guidelines
The Right to Refuse Medical Treatment
Report of the Law Reform Commission of Canada
The Medical Profession
Report of the Special Senate Committee on Euthanasia and Assisted Suicide
D. United States
E. Euthanasia and Assisted Suicide in the Netherlands
AND ASSISTED SUICIDE*
Because of advances in medical
treatment, people are now able to live longer and to delay death. But
the ability to live longer often entails a diminished quality of life
for those who suffer from degenerative or incurable diseases. The desire
to be spared from prolonged suffering, the increased incidence of seriously
disabilitating diseases such as AIDS and Alzheimers Disease, and
a better understanding of how medical technology can prolong life and
affect the dying process, among other things, have fuelled the desire
to achieve greater control over decisions relating to life and death.
These factors have also fostered a renewed interest in euthanasia and
cessation of medical treatment.
This paper will examine the social and legal
issues associated with these subjects.
BACKGROUND AND ANALYSIS
Although the definitions
used in discussions of euthanasia and assisted suicide can vary, the following
are based on the report of the Special Senate Committee on Euthanasia
and Assisted Suicide. Euthanasia is the deliberate act undertaken
by one person with the intention of ending the life of another person
in order to relieve that persons suffering. Assisted suicide
is the act of intentionally killing oneself with the assistance of another
who provides the knowledge, means or both.
occurs when the act is done in accordance with the wishes of a competent
individual or a valid advance directive. Non-voluntary euthanasia
occurs when the act is done without knowledge of the wishes of a competent
individual or with respect to an incompetent individual. Involuntary
euthanasia, which is indistinguishable from murder or manslaughter,
occurs when the act is done against the wishes of a competent individual
or a valid advance directive.
A competent individual is capable
of understanding the nature and consequences of the decision to be made
and capable of communicating this decision. An incompetent individual
is not capable of understanding the nature and consequences of the decision
to be made, and/or is not capable of communicating the decision.
A. Historical Background
Despite the fact that euthanasia
has gained considerable media attention of late, neither the practice
nor the controversy it engenders are new. While we now stress the conceptual
distinctions between euthanasia, suicide and cessation of treatment, in
early times euthanasia was generally equated with suicide. The tolerance
for suicide that developed during the ancient classical period to some
extent reflected a disdain for weakness, illness and the inability to
contribute to society past a certain age. At the same time, however, it
also reflected a concern for a "worthy and good life," something
that was elusive in the presence of extensive physical decline. In classical
times, the Greeks and the Romans succeeded in moving suicide out of a
dark and mysterious realm into the field of public discourse and debate.
An intolerance for suicide
began to take hold in the second and third centuries and gained increasing
momentum under the influence of Christianity. Whereas in the classical
period suicide was criticized only if it was irrational or without cause,
Christianity saw this act as a direct defiance of or interference with
Gods will; thus suicide resulted in the denial of a Christian burial
and tended to bring great shame upon family members. St. Augustine declared
that "life and its sufferings are divinely ordained by God and must
be borne accordingly." In the thirteenth century, the teachings of
St. Thomas Aquinas epitomized the intolerance for suicide. According to
him, suicide violated the biblical commandment against killing and was
ultimately the most dangerous of sins because it precluded an opportunity
The impact of the scientific
and medical discoveries of the sixteenth, seventeenth and eighteenth centuries
changed the nature of the debate on suicide. The increasing ability of
physicians to treat bodily ailments and extend life, caused the state
to have a more direct interest in questions of life and death in the medical
context. Strict adherence to religious principles and teachings was complicated
by the advances of science and medicine. Issues such as medically assisted
death and cessation of treatment, which characterize much of the contemporary
debate, have their roots in this period. By the beginning of the nineteenth
century, the medical profession was engaging in a fair amount of discussion
on euthanasia, in which philosophers and theologians joined. Much of the
discourse focused on the issue of "quality of life" and on the
right to determine when this quality had deteriorated to the point where
it was acceptable to cease living.
In recent memory, the question of quality
of life and cessation of treatment was perhaps best exemplified for the
public in the United States case of Karen Ann Quinlan, a 21-year old who
had suffered permanent brain damage after an episode involving the consumption
of alcohol and drugs. Ms. Quinlans parents signed a release form
to allow physicians to cease use of a respirator in the treatment of their
daughter. When the hospital refused to follow the directive, her parents
requested the courts to reverse the hospitals decision. In 1976,
following a ruling by the New Jersey Supreme Court, the respirator was
removed. Ms. Quinlan died in 1985 in a nursing home where she had remained
in a coma, fed through tubes, for some ten years. In the opinion of experts
in the field, this case had a profound effect upon public opinion and
B. Policy Considerations
In euthanasia and cessation
of treatment, the link between law, morality and social policy is not
clear-cut. This creates especially difficult problems for those with the
responsibility to develop and apply concrete policies. A range of social
conditions ought to inform current thinking about health and social policy
and euthanasia or cessation of treatment.
1. Chronic and Incurable Diseases
The advance of chronic conditions
such as Alzheimers Disease and incurable diseases such as AIDS and
cancer often means that afflicted people can see their probable future
before they become incapacitated. This may prompt them to lobby for more
direct input into their medical care; in some cases they will seek assistance
to die. Indeed, The Canadian AIDS Society in its brief to Legislative
Committee H during the 1991 hearings on Bill C-203, An Act to amend the
Criminal Code (terminally ill persons) expressed the hope that "death
may come to be seen not as a failure on the part of active medical care,
but rather as an expression of the qualities of dignity, compassion and
respect for the right of individuals to choose."
2. Medical Technology
The extent to which medical
technology can prolong life, quite independent of considerations about
the quality of that life, has become common knowledge for most citizens.
This means that many persons give active consideration to the limits they
will place on their own medical treatment and that of family members.
3. Health Care Costs and an Aging Population
The increasing cost of health
care in most countries is another relevant consideration. Estimates indicating
that individuals incur their highest health care costs in the final days
of life illustrate the delicate balance between sustaining life and containing
health care expenses. This fact, some health policy analysts insist, will
become increasingly apparent as more and more of the population move into
the older age groups, in which health care needs and their attendant costs
increase. The situation may be exacerbated when there are fewer people
in the work force to supply the tax revenue that is necessary for health
4. Palliative Care
Policy decisions must also
affect the issue of palliative and hospice care. Some physicians fear
that support for active and/or voluntary euthanasia will short-circuit
research into better and more effective palliative care. They argue that
hospice care for terminally ill patients, which greatly increases the
quality of their final stages of life, may be sacrificed for a policy
of active euthanasia.
C. Canadian Law
1. The Criminal Code
A number of provisions of
the Criminal Code impinge upon the issues of euthanasia and cessation
Section 14 of the Code provides
No person is entitled
to consent to have death inflicted on him, and such consent does not
affect the criminal responsibility of any person by whom death may be
inflicted on the person by whom consent is given.
In the medical context,
a doctor who, at a patients request, gives the patient a lethal
injection would be criminally liable.
Section 45 affects the right
of a patient to refuse medical treatment. It provides:
Everyone is protected
from criminal responsibility for performing a surgical operation on
any person for the benefit of that person if
the operation is
performed with reasonable care and skill; and
it is reasonable
to perform the operation, having regard to the state of health
of the person at the time the operation is performed and to all
the circumstances of the case.
Once medical treatment has
begun, there is a duty on the physician to use reasonable care, skill
and knowledge in administering therapy whose discontinuation would endanger
life. This duty is clearly expressed in section 217 of the Criminal
Code, which stipulates that:
Everyone who undertakes
an act is under a legal duty to do it if an omission to do the act
is or may be dangerous to life.
A number of other provisions
of the Criminal Code may also come into play, depending upon the
circumstances; these provisions include section 215 (Duty of Persons to
Provide Necessaries), section 216 (Duty of Persons Undertaking Acts Dangerous
to Life), section 219 (Criminal Negligence), section 220 (Causing Death
by Criminal Negligence), section 221 (Causing Bodily Harm by Criminal
Negligence), section 222 (Homicide), section 229 (Murder), section 231
(Classification of Murder), section 234 (Manslaughter), section 245 (Administering
Noxious Things) and the various assault and bodily harm provisions.
Theoretically, one would
expect euthanasia to be prosecuted as first degree murder, since there
is an intent to cause death, which is the definition of murder, and the
act is most often planned and deliberate, which is the definition of first
degree murder. However, charges of euthanasia have most often been influenced
by other criteria: the fact that the primary intent is to relieve suffering,
the unpredictable attitude of juries, and technical difficulties in proving
the exact cause of death when a person is in any case close to death and
taking considerable pain medication.
Charges in Canada have ranged from administering
a noxious substance, to manslaughter, to murder.
2. Aiding Suicide
Under section 241 of the
Criminal Code, it is an offence to counsel or to aid suicide, although
suicide itself is no longer an offence. The validity of section 241 under
the Canadian Charter of Rights and Freedoms was challenged in the
1992 case of Sue Rodriguez, a woman suffering from amyotrophic lateral
sclerosis or Lou Gehrigs disease. Ms. Rodriguez sought
to have the section struck down on the grounds that it prohibits a terminally
ill person from committing physician-assisted suicide. She argued that
her right to "life, liberty and security of the person," which,
in her view, includes the right to control the method, timing, and circumstances
of death, were denied by section 241.
The British Columbia Supreme
Court ruled that section 241 does not deprive Ms. Rodriguez of her
right to life, liberty and security of the person, nor does it restrict
her freedom of choice or affect her ability to make fundamental decisions
about her life. In the courts view, it is the nature of her illness,
not the legal system or the state, that deprives Ms. Rodriguez of
the ability to carry out her wishes. The court also concluded that section
241 does not discriminate against persons on the grounds of physical disability.
This decision was appealed
to the British Columbia Court of Appeal, which, in March 1993, dismissed
the appeal in a 2 to 1 decision. Both of the justices who favoured dismissal
felt that the matter should be dealt with by Parliament rather than the
courts. In deciding whether section 241 violated section 7 of the Charter,
Mr. Justice Hollinrake held that, although section 241 of the Criminal
Code may deprive Ms. Rodriguez of her right of security of the person
under section 7 of the Charter, the prohibition against physician-assisted
suicide was not contrary to the principles of fundamental justice.
The Chief Justice, however,
would have allowed the appeal. He concluded that section 241 violated
Ms. Rodriguezs section 7 rights to liberty and security of the person
and went on to state that "...any provision which imposes an indeterminate
period of senseless physical and psychological suffering upon someone
who is shortly to die anyway cannot conform with any principle of fundamental
Ms. Rodriguez appealed to
the Supreme Court of Canada, which, in a five to four decision, dismissed
the appeal. Ms. Rodriguez had argued before the Court that section 241(b)
of the Criminal Code, which makes it an offence to aid or abet
suicide, violates sections 7, 12 and 15 of the Charter.
The majority of the Court
held that, although section 241(b) deprives Sue Rodriguez of her security
of the person under section 7 of the Charter, the deprivation is justified
because it accords with principles of fundamental justice. Writing for
the majority, Mr. Justice Sopinka noted that respect for life is a fundamental
principle upon which there is substantial consensus in Canadian society.
The prohibition against assisted suicide reflects this consensus and is
designed to protect the vulnerable who might be persuaded to commit suicide.
To allow physician-assisted suicide, he observed, would erode the belief
in the sanctity of human life and suggest that the state condones suicide.
Furthermore, concerns about abuse and the difficulty in establishing safeguards
to prevent abuse make it necessary to prohibit assisted suicide.
The majority also refused
to find that section 241(b) constituted cruel and unusual treatment under
section 12 of the Charter.
Mr. Justice Sopinka assumed
that Ms. Rodriguezs equality rights under section 15(1) of
the Charter had been infringed, but concluded that the infringement was
justified under section 1 of the Charter. The purpose of s. 241(b),
he noted, is to protect individuals from others who may wish to control
their lives. To create an exception to the prohibition against assisted
suicide for some groups or individuals would create inequality and lend
support to the notion that we are starting down the "slippery slope"
toward full recognition of euthanasia. He considered the creation of safeguards
to prevent abuse unsatisfactory and insufficient to calm fears of the
likelihood of abuse. Even if an exception could be made for the terminally
ill, he felt there could be no guarantee that assisted suicide could be
limited to those who genuinely wished to die.
In her dissenting opinion,
Madam Justice McLachlin held that section 241(b) violates section 7 of
the Charter. She concluded that it would be contrary to the principles
of fundamental justice to deny Sue Rodriguez the choice available to those
who are physically able, merely because of a fear that others might suffer
abuse. She felt that Sue Rodriguez was being treated as a "scapegoat"
for others who might be improperly persuaded to commit suicide.
Chief Justice Lamers
dissent was based on section 15(1) of the Charter. He concluded that section
241(b) creates an inequality in that physically disabled persons unable
to commit suicide without assistance are prevented from choosing that
option without breaking the law; those who are capable of ending their
lives unassisted, however, may commit suicide with impunity. While the
Chief Justice was concerned that the decriminalization of assisted suicide
might increase the risk for those vulnerable to manipulation by others,
he contended that speculation to this effect and the fear of a "slippery
slope" could not justify the restriction on those who are not vulnerable
and who would freely consent to suicide.
In his dissent, Mr. Justice Cory agreed
with the disposition of the appeal proposed by Chief Justice Lamer for
the reasons put forward by the Chief Justice and Madam Justice McLachlin.
He would give the right to die with dignity protection under s. 7
of the Charter and allow terminally ill patients to obtain assistance
to terminate their lives.
3. The British Columbia Guidelines
In November 1993, the British
Columbia Ministry of the Attorney General issued guidelines for Crown
Counsel with respect to charging individuals who, out of compassion for
the deceased, participate in causing a death. Under the guidelines, Crown
Counsel will approve a prosecution only where there is a "substantial
likelihood of conviction and the public interest requires a prosecution."
In determining whether a
substantial likelihood of conviction exists, Crown Counsel will be required
to classify the conduct of the person involved in the death and the resulting
consequences as "active euthanasia," "assisted suicide,"
"palliative care," or "withholding or withdrawing medical
treatment." The factors to be considered in characterizing such conduct
include the provable intention of the person and, in cases involving physicians
and their patients, the position of the Canadian Medical Association and
expert medical opinions as to generally accepted ethical medical practices.
The public interest criterion
involves a consideration of the following factors:
- supporting proper professional and ethical
standards for health care professionals;
- societys interest in protecting
vulnerable persons; and
- societys interest in protecting
the sanctity of human life, while recognizing this does not require
life to be preserved at all costs.
According to the guidelines, palliative
care and withholding or withdrawing medical treatment will not be subject
to criminal prosecution when provided or administered according to accepted
ethical medical standards.
4. The Right to Refuse Medical
The common law recognizes
the right of an adult, competent person to refuse medical treatment or
to demand that treatment, once begun, be withdrawn or discontinued.
In a 1990 decision, the
Ontario Court of Appeal held that instructions on blood transfusions issued
when a patient was competent had to be followed even when she was incapable
of making a decision. The Court found that the physician must follow a
Jehovahs Witnesss written instruction refusing all blood transfusions,
even in an emergency situation where the patient was unable to give consent.
However, the Court emphasized that its decision applied only to the specific
case before it and not to situations of terminal or incurable illness
where a patient seeks to reject medical treatment by way of a living will
or an advance medical directive or to situations where the family of a
person in a persistent vegetative state wishes to withdraw medical treatment.
In the January 1992 decision
in the case of Nancy B., the Quebec Superior Court ruled that a competent,
adult patient suffering from an incurable disease and bedridden for life
had the right to request that her doctor disconnect the respirator keeping
her alive. In making his decision, Mr. Justice Dufour cited sections of
the Quebec Civil Code which provide that the human person is inviolable
and that no one can be made to undergo treatment without consent.
The case also dealt with the issue of the
criminal liability of the doctor who, at Nancy B.s request, would
be required to remove her from the respirator. After referring to sections
216, 217, 45 and 219 of the Criminal Code, as well as the provisions
dealing with homicide, the judge concluded that it was neither unreasonable
nor wanton and reckless conduct for a physician, at the request of a patient,
to disconnect the patients respirator and allow the patients
disease to take its natural course. He also found that the doctor would
not be aiding the patient to commit suicide or committing an act of homicide,
since Nancy B.s death would result from the underlying disease.
5. Report of the Law Reform Commission
In 1983, the Law Reform
Commission of Canada (the "Commission") published its Report
on Euthanasia, Aiding Suicide and Cessation of Treatment following
a Working Paper on the subject which had been published the previous year.
The Commission noted that
there was widespread consensus in Canada on three basic principles that
are reflected in our law. The first is that the protection of human life
is a fundamental value. The second is that the patient has the right to
autonomy and self-determination in making decisions about his or her medical
care. The third is that human life needs to be considered from a quantitative
and qualitative perspective.
The Working Paper and the
Report sought to answer three questions. Should active euthanasia be legalized
or at least decriminalized? Should aiding suicide be decriminalized? Should
certain provisions of the Criminal Code be revised to define the
legal parameters of the cessation and refusal of medical treatment?
After a thorough analysis
of the issues, the Commission concluded that neither active euthanasia
nor aiding suicide should be legalized and recommended retention of the
present law in those two areas. It recommended, however, that amendments
be made to ensure that criminal liability would not ensue from administering
any palliative care that had the effect of reducing a patients life
expectancy. The Commission also recommended that the Criminal Code
be amended to remove the ambiguity created by some current provisions
that appear to place an absolute duty on a physician to continue treatment
once it has begun.
Subsequent to the publication of its report
on euthanasia, the Commission recommended that the General Part of the
Criminal Code contain a provision that no one has a duty to continue
medical treatment which is therapeutically useless or for which consent
is expressly refused or withdrawn. This recommendation, however, did not
define "therapeutically useless" or set out the requirements
6. Advance Directives
A number of provinces have
sought to deal with the issue of medical treatment in the event of a patients
future incompetence. Advance directives have emerged as one method of
response to the problem. Commonly known as a "living will,"
an advance directive is a document signed by a competent individual dealing
with health care decisions to be made in the event that the person becomes
incapable of making those decisions. In the Quebec Civil Code,
an advance directive is referred to as a "mandate."
Advance directives can be
divided into two categories -- instruction directives and proxy directives.
In an instruction directive, an individual sets out what or how
health care decisions are to made in the event that he or she becomes
incompetent. In a proxy directive, an individual sets out who is
to make such health care decisions on his or her behalf.
Advance directives can be
interpreted in one of two ways:
judgement" uses a subjective test to seek to determine what decision
the incapacitated person would have made had he or she been capable
of doing so. The court looks at any opinions about terminating life-sustaining
treatment that the person may have expressed before becoming incompetent.
In some states, the courts require "clear and convincing"
evidence of the incompetent persons prior decision to forgo
such treatment. Some courts have adopted more relaxed evidentiary
requirements and relied on distant and occasional opinions expressed
by the incompetent person; still others have considered the patients
prior religious beliefs, lifestyle choices and the opinions of family
and friends as to the type of treatment he or she would have chosen.
interests" test involves an examination of the benefits and burdens
of continued treatment. Among the factors considered are the persons
present condition, degree of pain, prognosis and the risks, side effects
and benefits of various forms of treatment. In some situations, the
quality of life and the interests of the persons family are
also taken into account.
7. The Medical Profession
In 1995, the Canadian Medical
Association issued a policy summary on physician-assisted death, a phrase
that includes both euthanasia and assistance in suicide. The phrase does
not, however, include the withholding or withdrawal of inappropriate,
futile or unwanted medical treatment or the provision of compassionate
palliative care, even when these practices shorten life. The policy is
that CMA members should specifically exclude participation in euthanasia
and assisted suicide.
8. Report of the Special Senate Committee
on Euthanasia and Assisted Suicide
In February 1994,
the Senate of Canada established a Special Committee to study the issues
of euthanasia and assisted suicide. Issued in June 1995, the Report of
the Special Committee, Of Life and Death, also canvassed a number
of related issues including palliative care, pain control and sedation
practices, withholding and withdrawal of life-sustaining treatment and
The Special Committee urged
all levels of government in Canada to make palliative care programs a
top priority and to develop national guidelines and standards for such
care. The Special Committee felt that there was no moral difference between
withholding and withdrawing life-sustaining treatment. In either case,
the wishes of a competent patient should be respected. The report recognized
that there was uncertainty on the part of the medical profession and the
public as to what is legally permissible and recommended that practice
in the area be clarified in law.
The question of assisted
suicide was more contentious. Some Committee members favoured changes
to the existing law, while others opposed such changes. A majority of
the members recommended that the provision of the Criminal Code
that proscribes aiding and abetting suicide remain intact.
For the purposes of the
report, the Special Committee defined euthanasia as "the deliberate
act undertaken by one person with the intention of ending the life of
another person in order to relieve that persons suffering where
that act is the cause of death."
The Report then set out
three types of euthanasia: voluntary, nonvoluntary and involuntary. Euthanasia
is voluntary when it is conducted in accordance with the wishes of a competent
individual. It is nonvoluntary when it is done without the actual knowledge
of the wishes of the patient. Involuntary euthanasia is euthanasia that
is performed against the wishes of an individual. In Canada, the Criminal
Code makes all forms of euthanasia illegal.
The majority of the Committee
members opposed voluntary euthanasia, recommending that it continue as
a criminal offence, but with a less severe penalty in cases where mercy
or compassion is an element. The minority recommended that the Criminal
Code be amended to permit voluntary euthanasia for competent individuals
who are physically incapable of committing assisted suicide.
Nonvoluntary euthanasia would also remain
a criminal offence. The Committee, however, recommended that a less severe
penalty be applied where compassion or mercy is an element. The Committee
was unanimous in its conclusion that involuntary euthanasia continue to
be treated as murder under the Criminal Code.
9. Recent Events
The most notorious, and
controversial, euthanasia case in Canada occurred after Robert Latimer
had killed his disabled 12-year-old daughter Tracy in 1993 by placing
her in the family truck and then piping exhaust fumes into it. Evidence
showed that Tracy had a severe form of cerebral palsy, and could not walk,
talk or feed herself. She had suffered considerable pain; Mr. Latimer
told the police that "his priority was to put her out of her pain."
Mr. Latimer was charged
with first-degree murder, convicted of second-degree murder by a jury,
and sentenced to life imprisonment with no possibility of parole for ten
years. He subsequently lost an appeal to the Saskatchewan Court of Appeal.
However, in February 1996 the Supreme Court of Canada agreed to hear a
further appeal, and in June 1996, the original Crown prosecutor was charged
with attempting to obstruct justice through jury tampering. In February
1997, the Supreme Court of Canada ordered a new trial for Mr. Latimer
because of the allegations of jury tampering.
In late 1997, Mr. Latimer
was again found guilty of second-degree murder. At the sentencing hearing,
Mr. Latimers lawyer argued that he should be given a "constitutional
exemption," or that the judge should find the mandatory minimum sentence
of ten years to be "cruel and unusual punishment" in the circumstances,
and therefore a violation of Mr. Latimers rights under the Canadian
Charter of Rights and Freedoms. On 1 December 1997, in a decision
that surprised most legal commentators, the sentencing judge found that
a ten-year sentence would indeed be "grossly disproportionate"
to the offence. He sentenced Mr. Latimer to two years less a day, half
of which would be served in a provincial jail and half on his farm. The
sentence has been appealed.
There were several other
developments in Canada in 1997. A Toronto AIDS doctor plead guilty to
two charges of assisted suicide. A Montreal woman who, in a depressed
state, had drowned her six-year-old autistic son before attempting suicide
was given a suspended sentence. A biography of Margaret Laurence, a well-known
Canadian writer, claimed that she had committed suicide. Quotations given
from her diary seem to epitomize the feelings of some people with a terminal
illness (lung and kidney cancer in her case): "fear of pain, of being
a burden, of being controlled by doctors."
In British Columbia, there
was an inquest into the death of a 10-year-old girl with Rett syndrome,
a rare neurological disorder that, among other symptoms, can cause severe
eating disorders. At the time of her death, Katie Lynn Baker reportedly
weighed only 22 pounds, was severely disabled and could not speak, being
virtually non-communicative to all except her closest caregivers. According
to the coroners report, when hospitalization became the only way
to save Katie, her mother had sought "the childs wishes respecting
being hooked-up or force fed, which [the] mother interpreted
as being in the negative." To isolate Katie from the possibility
of non-consensual treatment, she was moved by her mother from the family
home to a new location, where she died a few days later.
The jury found that death
had been caused by "severe malnutrition" as a result of "inadequate
nutritional intake over a period of time caused directly or indirectly
by the actions of other persons." The jury classified the death as
"homicide"; however, the presiding coroner noted that "the
jurys ruling of death by homicide precludes any assumption of culpability
on the part of any person or agency. In the Coroners Inquest, the
term is neutral and does not imply fault or blame."
Another momentous event
in this area in 1997 was the arrest, on 6 May in Halifax, of Dr. Nancy
Morrison on a charge of first-degree murder in the death of a terminally
ill cancer patient. The hospital consulted an external review team whose
report was made public in July 1997; and describes the major events.
- Mr. Mills had cancer of the esophagus,
which required removing the esophagus and repairing the gap by repositioning
the stomach. The first three operations were unsuccessful, and the patient
was transferred from New Brunswick to Halifax on 29 September 1996.
- All possible treatment methods were unsuccessful.
By 9 November 1996, there was no hope of recovery. The patients
family was consulted and, "consistent with normal and usual procedures
in such circumstances, it was agreed by all those present that active
life support would be discontinued."
- Mr. Mills died on 10 November 1996.
"In addition to the pain killing and sedative drugs which are given
routinely to patients like Mr. Mills to relieve suffering during the
dying process, it is alleged that he was also given a medication that
is considered to be outside ethical and acceptable medical practice
a serious matter."
Confusing the issue was
the fact that the hospital did not consult the Medical Advisory Committee,
the Board of Directors, the College of Physicians and Surgeons of Nova
Scotia or the Chief Medical Examiner about the occurrence. Mr. Mills
family did not become aware that there had been an unusual incident until
Dr. Morrison was placed under arrest on the charge of first-degree murder.
The external review found
that the response of the administrative and medical leadership of the
hospital had been "indecisive and inappropriate." Reviewers
added that, they believed "those involved did not act with any sinister
or corrupt motives, but rather with the desire to avoid potentially disproportionate
consequences both for the physician and for the hospital." Presumably
for this reason, one of their recommendations was as follows:
recommended that Canadian legislators and law reform commissions
recognize the need to introduce a distinction in the criminal code
sections dealing with the punishment for first degree murder between
those moved by compassion and those moved by evil intent or personal
gain. We share the view expressed by many that a criminal code charge
that does not distinguish between those motivated by compassion
and Mr. Paul Bernado exposes itself to possible ridicule and subversion
In February 1998, Judge
Hughes Randall declined to commit Dr. Morrison to stand trial. He noted
that Mr. Mills had been given extraordinary amounts of Dilaudid, morphine
and other painkillers prior to Dr. Morrisons involvement. Although
potentially lethal, these earlier drugs had been legally administered
in an unsuccessful attempt to relieve the intense suffering that Mr. Mills
appeared to be suffering after being removed from the respirator. Judge
Randall found that, whatever Dr. Morrisons intentions when she allegedly
administered potassium chloride, Mr. Mills could have died from either
the enormous amount of painkillers received earlier or, because the intravenous
line delivering the various drugs to Mr. Mills was not working, from natural
causes. The Crown prosecutor has appealed the dismissal of the charge.
D. United States
In a few U.S. states, activists
in the "death with dignity" movement have sought to expand the
scope of living will statutes to permit physicians to provide aid-in-dying.
Writing in the 5 November
1992 issue of the New England Journal of Medicine, three doctors
urged the adoption of a new public policy to allow physician-assisted
suicide. This, they suggested, would achieve a balance between responding
to patients needs and protecting the vulnerable. The authors proposed
seven clinical criteria that would allow physicians to respond to requests
for assisted suicide from competent, incurably ill patients.
In November 1994, Oregon
voters passed Measure 16 which would allow a terminally ill adult resident
of Oregon, diagnosed with less than six months to live, to obtain a prescription
for medication to end his or her life. Before a physician could issue
such a prescription, certain conditions would have to be met. The patient
would have to make two oral and one written request for medication and
would require a second medical opinion. In addition, at least 15 days
would have to have elapsed since the initial request for a prescription.
A legal challenge to the
legislation prevented its proclamation, and in August 1995 a District
Court judge found it to be unconstitutional and invalid. However, the
Ninth Court Circuit of Appeals found that the plaintiffs in the action
had no legal standing to challenge Measure 16. The Court did not decide
the constitutional merits of physician-assisted suicide and the United
States Supreme Court refused to hear an appeal.
In June 1997, the Oregon
legislature voted to send Measure 16 back to the electorate for a second
vote in November 1997, at which time the Oregon voters reaffirmed the
Act. Reportedly, at least four terminally ill people have since used the
provisions of the Act to end their lives.
In 1994, a Federal District
Court in Seattle had declared unconstitutional a Washington State law
prohibiting doctor-assisted suicide. In March 1995, a three-member panel
of the United States Court of Appeal for the Ninth Circuit overturned
this decision, stating that a right to doctor-assisted suicide had no
place in "the traditions of our nation" and was "antithetical
to the defence of human life that has been a chief responsibility of our
constitutional government." In March 1996, however, the full Ninth
Circuit reheard the case and decided, by an 8-3 majority, that the Washington
law prohibiting doctor-assisted suicide was indeed unconstitutional and
violated the liberty interest under the due process clause of the 14th
amendment. The decision was binding on all nine western states.
In April 1996, a three-member
panel of the United States Court of Appeal for the Second Circuit unanimously
struck down a similar law from New York. The court held that the New York
law, which made it illegal for doctors to help terminally ill patients
end their own lives, violated the equal protection clause of the 14th
amendment in that it protected the rights of patients on life support
to order their life support terminated, while denying comparable relief
to other terminally ill, mentally competent patients not on life support.
On 1 October 1996, the Supreme
Court of the United States agreed to hear an appeal of the two Court of
Appeal rulings. The Court had previously refused to hear an appeal of
a Michigan State Court decision upholding a Michigan law prohibiting assisted
suicide, passed after Dr. Kevorkian began his campaign of assisting terminally
ill people to die.
On 26 June 1997, the
Supreme Court reversed both Court of Appeal decisions, and upheld the
Washington and New York statutes prohibiting assisted suicide. However,
the courts finding that these two statutes are constitutional does
not mean that a law permitting assisted suicide would be found unconstitutional.
E. Euthanasia and Assisted Suicide
in the Netherlands
In the Netherlands, the
term "euthanasia" has one clear meaning and is normally not
qualified by adjectives such as voluntary or involuntary. The practice
is the deliberate termination of a patients life by a physician
acting on the patients request and according to strict guidelines.
Euthanasia is prohibited under the Dutch penal code, which states that
anyone who terminates the life of another person at that persons
explicit request is guilty of a criminal offence punishable by up to 12
years in prison.
Although it is a criminal
offence, however, euthanasia is practised in the Netherlands and is not
prosecuted, as long as certain guidelines are followed. These guidelines
were developed through a series of court decisions where physicians who
had been charged with practising euthanasia were found not to be criminally
liable for their action. Under the guidelines, all the following requirements
must be met:
- the patient must repeatedly and explicitly
express the desire to die;
- the patients decision must be well
informed, free and enduring;
- the patient must be suffering from severe
physical or mental pain with no prospect of relief (but need not be
options for care must have been exhausted (so that euthanasia is a
last resort) or the patient must have refused other available options;
must be carried out by a qualified physician;
- the physician must inform the local coroner
that the euthanasia has been carried out.
Until recently, reliable
estimates of the extent of euthanasia in the Netherlands were unavailable.
In September 1991, the Remmelink Commission (a Dutch government commission
of inquiry into euthanasia and other medical decisions about the end of
life) reported that its scientific studies had revealed about 2,300 cases
of euthanasia in the previous year in the Netherlands, representing 1.8%
of the years deaths. Many more requests (about 9,000) were made
for euthanasia in that year than were actually carried out (about 2,300).
Furthermore, the majority of patients who requested euthanasia (i.e. about
70%) were terminally ill cancer patients.
In February 1993, the lower
house of Parliament in the Netherlands passed legislation on the reporting
procedure for euthanasia. Although not legalizing euthanasia, the legislation
would guarantee immunity from prosecution to physicians who follow certain
guidelines for practising it.
In 1994, the Supreme Court
of the Netherlands decided the controversial Chabot case, finding
Dr. Chabot technically guilty of assisted suicide. Dr. Chabots patient,
Hilly Boscher, had been 50 years old and had simply not wished to live.
She had experienced a violent marriage, the death of one son by suicide
and the death of her second son from cancer. She had a 20-year history
of depression, and had attempted to commit suicide immediately after the
death of her second son. She was determined to commit suicide but wished
to do so in a humane way that would not be intrusive on others.
Dr. Chabot undertook to
work with her in the hope of altering her viewpoint, and suggested she
keep a journal. What emerged from this was Ms. Boschers unswerving
determination to die. Although there was no physical or psychiatric illness,
Dr. Chabot was of the opinion that she was experiencing intense, long-term
psychic suffering with no prospect of improvement. He sent transcripts
of the therapy sessions to seven expert colleagues, all of whom agreed
with his assessment. Considering the situation hopeless, Dr. Chabot considered
that the lesser evil was to provide his patient with the means to commit
suicide painlessly and with as little violence as possible.
The Supreme Court accepted
the principle that assisted suicide could be justifiable when no physical
illness was present, but rather intense emotional or mental suffering.
However, the Court held that that such situations required extreme caution;
it found that Dr. Chabot had violated the procedural requirements in that
none of the seven experts had personally examined Ms. Boscher. Nonetheless,
the Court declined to impose a penalty on Dr. Chabot, which may well have
indicated ambivalence towards such a difficult situation. The issue of
assisting suicide as a relief from non-somatic (or non-physical) suffering
remains a contentious one.
In 1995, Dutch courts dealt
with two separate but similar cases in which doctors had ended the lives
of severely disabled infants, both in pain and not expected to survive
their first year. In both cases, the doctor had acted at the explicit
request of the childs parents. These cases illustrate the troubling
gap between the parents right to refuse treatment for their child,
with death as the inevitable result of such refusal, and their inability
to relieve pain during the dying process.
In August 1995, the Royal Dutch Medical
Association adopted new guidelines for euthanasia and assisted suicide.
These stated that, where possible, the patient, rather than the doctor,
should administer the drug. The new guidelines also emphasize that the
required consultation with a second physician should involve an experienced
doctor who has no professional or familial relationship with either the
patient or the first doctor.
In February 1995, the Chief
Minister of the Northern Territory of Australia introduced a Private Members
Bill, The Rights of the Terminally Ill Bill (1195) (NT), in the
Legislative Assembly. The bill was intended to provide terminally ill
persons with the right to request assistance from a medically qualified
person in voluntarily terminating their lives. A Select Committee on Euthanasia
was established to inquire into the bill and report back to the Legislative
Assembly. In May 1995, after over 50 amendments had been made to the original
bill, the Legislative Assembly passed the legislation by 15 votes to ten.
The Northern Territory thus became the first jurisdiction in the world
to legalize physician-assisted suicide and euthanasia.
Unsurprisingly, the bill
created considerable controversy, both within Australia and internationally.
There were calls for its repeal, and for the Governor-General of Australia
to disallow it under the Northern Territory (Self-Government) Act,
1978; however, the Administrator of the Northern Territory assented
to the Act in June 1995, and to regulations under the Act in June 1996.
These came into effect, with the Act itself, on 1 July 1996. In the interim,
the Northern Territory Legislative Assembly had passed further amendments
to the legislation, whereby the number of doctors involved was increased
from two to three, one of whom must be a qualified psychiatrist and another
a specialist in the patients illness.
The Rights of the Terminally
Ill Act 1995 (NT) included numerous administrative safeguards, as
well as numerous references to treatment and levels of suffering "acceptable
to the patient." Section 4 stated the essential philosophy of the
A patient who, in the
course of a terminal illness, is experiencing pain, suffering and/or
distress to an extent unacceptable to the patient, may request the
patients medical practitioner to assist the patient to terminate
the patients life.
A "terminal illness"
was defined as one that will result in the death of the patient unless
extraordinary measures, or treatment that is unacceptable to the patient,
are used. A medical practitioner who received a request for assistance
and followed all the procedures laid out in the legislation could legally
assist the patient to terminate his or her life. The assistance could
consist of prescribing or preparing a substance, which would be either
given to the patient for self-administration or would be administered
to the patient. Alternatively, the physician could, at any time and for
any reason, refuse to give such assistance.
The other criteria that
had to be met included the following: the patient had to be at least 18
years old; there could be no palliative care options reasonably available
to the patient that would alleviate pain and suffering to a level he or
she found acceptable; and there had to be two "cooling off"
periods, totalling nine days, between the first request to the doctor
and the assistance itself.
In an attempt to prevent
the bill from becoming law, the President of the Northern Territory Branch
of the Australian Medical Association, Dr. Wake, and an aboriginal leader,
Reverend Dr. Gondarra, challenged its validity. One of the grounds was
that the exercise of legislative power by the Legislative Assembly is
constrained by an obligation to protect an inalienable "right to
life," deeply rooted in the democratic system of government and the
common law. By a 2-1 majority, the court upheld the legislation, stating
that it need not decide whether the legislation infringed any fundamental
right since, in the absence of a constitutionally enshrined Bill of Rights,
that issue was "ethical, moral or political" in nature rather
Although some critics had
argued that the amended bill was too cumbersome to be workable, controversy
again erupted in late September 1996, when a Darwin man became the first
person to use the new legislation successfully. The patient had suffered
from prostate cancer for five years and, according to press reports, the
lethal injection was triggered by a lap-top computer through which the
patient confirmed his wish to die. Three other people used the provisions
of the Act before it was overruled by the national Parliament.
Under section 122 of the
Australian Constitution, the Commonwealth Parliament has a plenary power
to pass legislation overriding any territorial law. In September 1996,
Mr. Kevin Andrews, a government backbencher, introduced a Private Members
bill to overturn the Northern Territorys euthanasia law. The bill
passed the House of Representatives on 9 December 1996 and the Senate
on 24 March 1997.
On 8 November 1996, a Voluntary
Euthanasia bill was introduced into the Legislative Council of the state
of South Australia. In a vote on the future of the bill taken on 9 July
1997, it was decided by 13 votes to 8 that consideration of the bill would
continue and by 18 votes to 3 that the bill would be referred to a Select
Committee. In addition, it was proposed that the bill should be amended
to require a referendum to be held before the bill became law, in the
event that it was eventually passed by both Upper and Lower Houses.
Among the essential features
of the bill are:
- Euthanasia could take place only when
a person was hopelessly ill; for example, the person would have to have
an injury or illness that either resulted in permanent deprivation of
consciousness or irreversibly impaired the quality of life so that it
- The request would have to be made by
a person of sound mind, and could be either a Current Request, which
would take effect without further deterioration in the persons
condition, or an Advanced Request, which would take effect in the event
that the person became hopelessly ill.
- Only a doctor could administer euthanasia,
and there would have to be a second independent opinion. Both doctors
would have to be satisfied that the patient was not suffering from a
treatable clinical depression. Any health care worker could decline
to take part in the practice of euthanasia.
- Forty-eight hours would have to elapse
between the request and the administration of euthanasia.
- Life insurance policies would not be
- The Coroner and Parliament would have
to be informed of each death.
The bill and the Select
Committee both lapsed when state elections were called towards the end
of 1997. In March 1998 the bill was reinstated, however, and referred
to the Standing Committee on Social Development.
Until 1991, when Private
Members bills on the subject were introduced in the House of Commons,
euthanasia had received only fleeting references in the House and had
never been debated there. Introduced in close succession were: Bill C-203,
by Robert Wenman (Fraser Valley West), on 16 May 1991 and Bill C-261,
by Chris Axworthy (Saskatoon-Clarks Crossing), on 19 June 1991.
(Mr. Wenman had introduced Bill C-351 in March 1991 but it had died on
the Order Paper with the ending of the parliamentary session.) Mr. Axworthys
bill incorporated most of Mr. Wenmans "passive euthanasia"
bill but would have extended its scope to provide for "active euthanasia."
Mr. Wenmans bill,
An Act to amend the Criminal Code (terminally ill persons), was designed
to protect medical practitioners from possible criminal liability in three
treatment scenarios: first, where the practitioner withholds or withdraws
medical treatment at the request of a terminally ill patient; second,
where the practitioner withholds or withdraws medical treatment from a
terminally ill patient because the treatment is therapeutically useless
and not in the best interests of the patient; and third, where the practitioner,
to ease the suffering of the patient, provides palliative care, such as
pain-relieving drugs, whose side-effect might be to hasten the patients
death. In summary, the purpose of the bill was to protect medical practitioners
who provide proper and ethical treatment to their terminal patients but
who, by so doing, incur the possibility of violating certain sections
of the Criminal Code.
Mr. Wenmans bill was
not intended to provide for active euthanasia in any circumstances. It
would have allowed passive euthanasia to be practised, however, in that
a medical practitioner would not have been held criminally liable for
withdrawing life-sustaining treatment by, for example, turning off a respirator
at the request of a terminally ill patient.
Mr. Axworthys bill,
on the other hand, made no distinction between passive euthanasia, allowing
individuals to die by withholding or withdrawing treatment, and active
euthanasia, such as administering a lethal dose of a drug. This bill included
the same exculpatory provisions as Mr. Wenmans but added provisions
that would have legalized active euthanasia in certain conditions. The
bill proposed that a person suffering from an irremediable condition could
apply to a euthanasia referee for a "euthanasia certificate"
giving permission for the process.
Both bills were debated
in the House of Commons at second reading. Mr. Wenmans bill, which
was less controversial, was referred to a legislative committee for review.
Even those members who expressed reservations about the bill in the debate
were nevertheless in favour of its referral to a committee, since they
recognized a need to examine the issues it raised. Mr. Axworthys
bill, on the other hand, inspired very strong criticism during the debate
at second reading and was dropped from the Order Paper.
Following several weeks
of committee hearings, Mr. Wenmans bill also met an early demise.
The legislative committee charged with reviewing the bill, after completing
its hearings and without considering any amendments, decided to adjourn
the proceedings sine die. By adjourning without assigning a further
meeting date, the Committee effectively halted further parliamentary action
on the bill.
In December 1992, a Private
Members bill to legalize physician-assisted suicide was introduced
in the House of Commons by Mr. Svend Robinson. Three months later,
in March 1993, the House of Commons defeated a motion by Ian Waddell,
M.P. calling upon the government to consider the advisability of introducing
legislation on euthanasia. In February 1994, Mr. Svend Robinson introduced
another Private Members bill to legalize physician-assisted suicide
for terminally ill persons. This bill was subsequently debated and dropped
from the Order Paper.
On 23 February 1994, the
Senate passed a motion to create a special committee to examine and report
on the legal, social and ethical issues relating to euthanasia and assisted
suicide. The Report of the Special Committee, Of Life and Death,
was issued in June 1995.
On 4 November 1997, Mr.
Svend Robinson introduced Motion M-123, calling for a special committee
to be appointed to review the Criminal Code provisions dealing
with euthanasia and physician-assisted suicide and to prepare a bill.
On 25 March 1998, the motion was rejected by a considerable margin.
1983 - The Law Reform Commission
of Canada recommended against legalizing or decriminalizing voluntary
active euthanasia. It also recommended that aiding suicide not be decriminalized
where assistance has been rendered to a terminally ill person.
June 1987 - The Law Reform
Commission of Canada released proposals for amending the Criminal Code.
These included the recommendation that mercy killing be treated as second-degree
murder, ("ordinary murder,") rather than as first-degree ("premeditated
murder.") Second-degree murder would carry no fixed or minimum jail
16 May 1991 - Private Members
Bill C-203, An Act to amend the Criminal Code (terminally ill persons),
was read for the first time in the House of Commons.
19 June 1991 - Private Members
Bill C-261, An Act to legalize the administration of euthanasia under
certain conditions, was read for the first time in the House of Commons.
10 September 1991 - In the
Netherlands, findings from the first comprehensive study of Dutch euthanasia
practices were released by the Remmelink Commission.
24 September 1991 - Bill
C-203, An Act to amend the Criminal Code (terminally ill persons) received
second reading and was referred to Legislative Committee H for consideration.
The Committee began hearings on the bill on 29 October 1991.
24 October 1991 - Bill C-261,
An Act to legalize the administration of euthanasia, was debated at second
reading and dropped from the Order Paper.
6 January 1992 - The Quebec
Superior Court ruled in the case of Nancy B., a woman suffering from an
incurable disease, that turning off her respirator at her request and
letting nature take its course would not be a criminal offence.
30 January 1992 - An Ontario
surgeon was charged with second degree murder in connection with the death
of a seriously ill cancer patient. The patient is alleged to have died
of a cardiac arrest after having been administered morphine and potassium
18 February 1992 - Legislative
Committee H on Bill C-203 adjourned sine die.
August 1992 - Scott Mataya,
a Toronto nurse who had originally been charged with first-degree murder
in the mercy killing of a terminally ill patient, entered a guilty plea
to a lesser charge of administering a noxious substance. He received a
suspended sentence and was ordered to surrender his nursing licence.
22 March 1993 - Members
of the House of Commons defeated a motion that called upon the government
to consider the advisability of introducing legislation on the subject
of euthanasia and ensuring that those assisting terminally ill persons
who wish to die will not be subject to criminal liability.
April 1993 - An Ontario
physician who gave a lethal injection to a seriously ill cancer patient
was given a three-year suspended sentence after pleading guilty to a charge
of administering a noxious substance to endanger life. The physician was
originally charged with second-degree murder, but this charge was withdrawn.
30 September 1993 - In a
five to four decision, the Supreme Court of Canada dismissed an appeal
by Sue Rodriguez in which she challenged the validity of the Criminal
Code prohibition on assisted suicide under the Canadian Charter
of Rights and Freedoms.
3 November 1993 - The British
Columbia Ministry of the Attorney General issued guidelines for Crown
Counsel with respect to charging persons involved in cases of active euthanasia
and assisted suicide.
12 February 1994 - Sue Rodriguez
committed suicide with the assistance of a physician. The death is investigated
by police, but no criminal charge is laid.
14 February 1994 - Justice
Minister Allan Rock stated that the issues of cessation of treatment and
assisted suicide should be considered by Parliament.
15 February 1994 - Prime
Minister Chrétien stated that Members of Parliament would have a free
vote on whether to legalize doctor-assisted suicide.
16 February 1994 - Private
Members Bill C-215, An Act to amend the Criminal Code (aiding suicide),
was read for the first time in the House of Commons. This bill was debated
and dropped from the Order Paper on 21 September 1994.
23 February 1994 - A Special
Senate Committee was established to examine and report on the legal, social
and ethical issues relating to euthanasia and assisted suicide.
November 1994 - Robert Latimer
was convicted of second-degree murder in the asphyxiation death of his
severely disabled 12-year-old daughter Tracy and sentenced to life in
prison with no eligibility for parole for ten years.
June 1995 - The Special
Senate Committee on Euthanasia and Assisted Suicide issued its report
Of Life and Death.
February 1997 - The Supreme
Court of Canada ordered a new trial for Robert Latimer.
May 1997 - Dr. Nancy Morrison
was charged with the first-degree murder of a terminally ill patent who
had been removed from active life support.
December 1997 - Mr. Robert
Latimer, having again been convicted of second-degree murder, was sentenced
to two years less a day, notwithstanding that the minimum sentence by
law is ten years.
February 1998 - A Nova Scotia
judge found that there was not sufficient evidence for a jury to convict
Dr. Nancy Morrison, and refused to commit her to trial.
Cica, Natasha. Euthanasia
- The Australian Law in an International Context; "Part I: Passive
Voluntary Euthanasia," "Part II: Active Voluntary Euthanasia."
Research Papers 3 and 4, Parliamentary Library, Australia, 1996.
Dworkin, Ronald. Lifes
Dominion: An Argument about Abortion, Euthanasia and Individual Freedom.
Alfred A. Knopf, New York, 1993.
Humphry, Derek, et.al.
The Right to Die: Understanding Euthanasia. Harper and Row, New York,
The Ethics of Deliberate Death. Kennikat Press, Port Washington,
New York, 1981.
Law Reform Commission of
Canada. Euthanasia, Aiding Suicide and Cessation of Treatment.
Working Paper 28, 1982.
Law Reform Commission of
Canada. Euthanasia, Aiding Suicide and Cessation of Treatment.
Report 20, 1983.
Mullens, Anne. Euthanasia:
Dying for Leadership, Special report by Anne Mullens, winner of the
sixth annual Atkinson Fellowship in Public Policy, 1994. Atkinson Charitable
Foundation, Toronto, 1994.
Mullens, Anne. Timely
Death: Considering Our Last Rights. A.A. Knopf Canada, Toronto, 1996.
Senate of Canada. Of
Life and Death. Report of the Special Senate Committee on Euthanasia
and Assisted Suicide. June 1995.
Smith, Margaret. The
Rodriguez Case: A Review of the Supreme Court of Canada Decision on Assisted
Suicide. BP-349, Research Branch, Library of Parliament, Ottawa, October
Van Der Maas Paul J. et
al., "Euthanasia and Other Medical Decisions concerning the End
of Life." Lancet, Vol. 338, 14 September 1991, p. 669-674.
Nancy B. v.
Hôtel-Dieu de Québec (1992), 86 D.L.R. (4th) 385 (Que. S.C.).
v. British Columbia (Attorney General) (1993), 24 C.R. (4th) 281
The original version of this Current Issue Review was published in
February 1992; the paper has been regularly updated since that time.