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In 1991 and 1992, citizens in Washington  and California, respectively, voted on two referenda; these referenda sought to sanction legally both euthanasia and physician- assisted suicide, or physician-assisted dying. In both cases, voters defeated these referenda by very narrow margins--about 54 percent to 46 percent in both cases. However, in

1994, the citizens of Oregon were asked to vote on Measure 16, which asked, "Shall law allow terminally ill adult Oregon patients voluntary informed choice to obtain physician's prescription for drugs to end life?" (quoted in Campbell 1994, 9). In this case, the measure passed, which ultimately led to the Oregon Death with Dignity Act (see "The Oregon Death with Dignity Act," in Beauchamp et al. 2008, 404-406). The critical difference between this Oregon statute and those proposed in Washington and California is its restriction to physician-assisted suicide.

When Oregonian voters approved this measure in November 1994 by a very narrow margin, Oregon became "the only place in the world where doctors may legally help patients end their lives" (Egan 1994, A1). However, that was not the end of the story. The day before the measure was to become law, its enactment was blocked by a court challenge. In August 1995, a federal judge ruled the measure unconstitutional because "with state-sanctioned and physician-assisted death at issue, some 'good results' cannot out- weigh other lives lost due to unconstitutional errors and abuses" ("Judge Strikes Down Oregon's Suicide Law," A15).

In March 1996, the legal situation changed radically for the nine western states in the jurisdiction of the United States Court of Appeals for the Ninth Circuit, including Oregon. In an 8-3 ruling, this court struck down a Washington State statute that made assisting in a suicide a felony. While this ruling held only for the states in the Ninth Circuit, a very critical precedent was set. The grounds for the ruling were privacy and autonomy. Judge Stephen Reinhardt, writing for the majority, said: "Like the decision of whether or not to have an abortion, the decision how and when to die is one of 'the

most intimate and personal choices a person may make in a lifetime,' a choice 'central to personal dignity and autonomy'" (Lewin 1996, A14). The ruling also argued that not only doctors should be protected from prosecution "but others like pharmacists and family members 'whose services are essential to help the terminally ill patient obtain and take' medication to hasten death" (Lewin 1996, A14). Thus, the window opened for a round of appeals and argumentation. Later, a unanimous ruling of the three-judge Second Circuit Court of Appeals in New York reinforced this ruling in April 1996. This court stated "that doctors in New York State could legally help terminally ill patients commit suicide in certain circumstances" (Bruni 1996, A1). As the ruling was appealed, a critical countrywide debate began.

Additionally, Michigan passed a law explicitly prohibiting physician-assisted suicide; this was in response to the activities of Jack Kevorkian, whose activities include physician-assisted suicide. However, this law has passed out of existence because of specific time limits. Furthermore, Kevorkian was brought to trial for acts committed while this law was in effect but was found not guilty based on the jury's decision that his intent was to relieve pain, not to cause death. Notwithstanding  this, another murder charge was brought against Kevorkian in 1999. In this case, he was convicted and sentenced to prison.

Finally, three United  States Supreme Court  cases have become landmark  cases in the legal and ethical debates over physician-assisted suicide. In 1997, the U.S. Supreme Court adjudicated on two related cases (Beauchamp et al. 2008). First, the main question before the Court in Vacco v. Quill was whether New York's prohibition on assisting suicide violated the Equal Protection Clause of the Fourteenth Amendment. The Court held that it did not. Second, the main question before the Court in Washington v. Glucksberg was whether the "liberty" (i.e., the right to refuse wanted life-saving medical treatment) specifically protected by the due process clause includes a right to commit suicide, which includes a right to assistance in suicide. The Court held that the right to assistance in suicide is not a fundamental liberty inter- est protected by the due process clause. In the 2006 case of Gonzalez v. Oregon, the main question before the Court was whether the Controlled Substances Act allows the U.S. attorney general to prohibit doctors from prescribing regulated drugs for use in physician-assisted suicide, notwithstanding a state law prohibiting it (Beauchamp et al. 2008, 413-418). The Court of Appeals held that the interpretive rule exercised by the attorney general to restrict use of certain drugs was invalid; the Supreme Court held that the Court of Appeals was correct: its decision was affirmed.

In summary, these cases have three implications. One, they demonstrate that it is not unconstitutional for states to ban assisted suicide while protecting patients' rights to refuse life-sustaining treatment. Two, one cannot claim that physician-assisted suicide is a fundamental liberty interest protected in the same way as the right to refuse treatment. Finally, the executive branch at the federal level cannot use the Controlled Substances

Act to restrict physician-assisted suicide at the state level (which basically protected the practice of physician-assisted suicide in Oregon).

References:

Beauchamp, Tom  L., et al., Contemporary  Issues in Bioethics, 7th ed. Belmont, CA: Thomson Wadsworth, 2008.

Bruni, Frank, "Federal Ruling Allows Doctors to Prescribe Drugs to End Life." New York Times (April 3, 1996): A1.

Cahill, Lisa Sowle, Theological Bioethics:  Participation,   Justice, and Change. Washington,  DC: Georgetown University Press, 2005.

Callahan, Daniel, The Troubled  Dream of Life: In Search of a Peaceful Death. Washington, DC: Georgetown University Press, 2000.

Callahan, Daniel, What Kind of Life? The Limits of Medical Progress. Washington, DC: George- town University Press, 1995.

Campbell, Courtney  S, "The  Oregon Trail  to  Death:  Measure 16." Commonweal 121, no. 14 (August 1994).

Edelstein, Ludwig, "The Hippocratic Oath: Text, Translation and Interpretation." In Ancient Medicine, ed. Oswei Temkin and C. Lillian Temkin. Baltimore: Johns Hopkins University Press, 1967. Egan, Timothy, "Suicide Law Placing Oregon on Several Uncharted Paths." New York Times (November 25, 1994): A1.

Foley, Kathleen, and Herbert Hendin, eds., The Case against Assisted Suicide: For the Right to End- of-Life Care. Baltimore: Johns Hopkins University Press, 2002.

Gorsuch, Neil M., The Future of Assisted Suicide and Euthanasia. Princeton, NJ: Princeton University Press, 2006.

"Judge Strikes Down Oregon's Suicide Law," New York Times (August 4, 1995): A15.

Keown, John, ed., Euthanasia Examined: Ethical, Clinical, and Legal Perspectives. New York: Cam- bridge University Press, 1995.

Lammers, Stephen E., and Allen Verhey, eds., On Moral Medicine: Theological Perspectives in Medical Ethics, 2d ed. Grand Rapids, MI: William B. Eerdmans, 1998.

Lewin, Tamar,  "Ruling  Sharpens  Debate  on  'Right  to  Die,'"  New York  Times (March  8, 1996): A14.

McLean, Sheila, The Case for Physician Assisted Suicide. London: Pandora, 1997.

Mitchell, John B., Understanding Assisted Suicide: Nine Issues to Consider.  Ann Arbor: University of Michigan Press, 2007.

Ramsey, Paul, "The Indignity of 'Death  with Dignity.'" Hastings Center Studies 2, no. 2 (May 1974): 47-62.

Rietjens, Judith A.C., et al., "Terminal Sedation and Euthanasia: A Comparison of Clinical Practices." Archives of Internal Medicine 166 (2006): 749-753.

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