Preface - Executive Summary and Introduction

     Governor Mario M. Cuomo convened the Task Force on Life and the Law in
 1984, giving it a broad mandate to recommend public policy on issues
 raised by medical advances.  That mandate included decisions about
 life-sustaining treatment.  Assisted suicide and euthanasia were not on
 the agenda initially presented to the Task Force.  Nor was the prospect of
 legalizing the practices even remotely part of public consideration at
 that time.

     Recently, however, public debate about the practices has intensified.
 Although no major efforts to legalize assisted suicide and euthanasia have
 been launched in New York State, we chose to examine the practices and to
 release this report in order to contribute to the debate unfolding in New
 York and nationally.

     Since the Task Force's inception, we have proposed four laws to
 promote the right to decide about medical treatment, including
 life sustaining measures.  Three of those proposals, establishing proce-
 dures for do-not-resuscitate orders in health care facilities and in
 community settings, and authorizing individuals to create health care
 proxies, are now law.  Our fourth proposal for legislation is pending
 before the New York State Legislature.  It would grant family members and
 others close to the patient the authority to decide about treatment,
 including life-sustaining measures, for individuals who are too young or
 too ill to decide for themselves and who have not left advance treatment
 instructions or signed a health care proxy.

     In this report, we unanimously recommend that New York laws
 prohibiting assisted suicide and euthanasia should not be changed.  In
 essence, we propose a clear line for public policies and medical practice
 between forgoing medical interventions and assistance to commit suicide or
 euthanasia.  Decisions to forgo treatment are an integral part of medical
 practice; the use of many treatments would be inconceivable without the
 ability to withhold or to stop the treatments in appropriate cases.  We
 have identified the wishes and interests of patients as the primary
 guideposts for those decisions.

     Assisted suicide and euthanasia would carry us into new terrain
 American society has never sanctioned assisted suicide or mercy killing.
 We believe that the practices would be profoundly dangerous for large
 segments of the population, especially in light of the widespread
 failure of American medicine to treat pain adequately or to diagnose
 and treat depression in many cases.  The risks would extend to all
 individuals who are ill.  They would be most severe for those whose
 autonomy and well-being are already compromised by poverty, lack of access
 to good medical care, or membership in a stigmatized social group.  The
 risks of legalizing assisted suicide and euthanasia for these individuals,
 in a health care system and society that cannot effectively protect
 against the impact of inadequate resources and ingrained social
 disadvantage, are likely to be extraordinary.

     The distinction between the refusal of medical treatment and assisted
 suicide or euthanasia has not been well-articulated in the broader public
 debate.  In fact, the often-used rubric of the "right to die" obscures the
 distinction.  The media's coverage of individual cases as a way of
 presenting the issues to the public also blurs the difference between a
 private act and public policy; between what individuals might find
 desirable or feasible in a particular case and what would actually occur
 in doctors' offices, clinics, and hospitals, if assisted suicide and
 euthanasia became a standard part of medical practice.  Public opinion
 polls, focusing on whether individuals think they might want these options
 for themselves one day, also offer little insight about what it would mean
 for society to make assisted suicide or direct killing practices
 sanctioned and regulated by the state or supervised by the medical
 profession itself.

     We hope that this report will highlight certain critical distinctions
 and questions for public consideration.  We also hope that the report and
 our recommendations will improve access to pain relief and the palliation
 of symptoms, not only for those who are terminally ill or contemplating
 suicide, but for all patients.

     We sought the opinions and expertise of many individuals while
 developing our recommendations.  We extend our gratitude to all those who
 generously lent their time and perspective to our discussion.  Four
 individuals served as consultants in our deliberations:  Nessa Coyle,
 R.N., Jimmie Holland, M.D., Diane Meier, M.D., and Norton Spritz, M.D. The
 report does not necessarily reflect their personal views about assisted
 suicide and euthanasia, but it does reflect their experience and insight
 in caring for those who are severely and terminally ill.  We benefitted
 greatly from their expertise and their participation with us as we
 explored these difficult questions.  We also extend our gratitude to Chris
 Hyman and Peter Millock who provided invaluable guidance throughout our

	      The Members of the Task Force on Life and the Law





    Over the past two decades, the right to decide about medical treatment,
 including the right to refuse life-sustaining measures, has become a
 fundamental tenet of American law.  The Task Force has sought to make this
 right a reality for the citizens of New York State, recommending legislation
 on do-not-resuscitate orders, health care proxies, and, most recently,
 surrogate decision making for patients without capacity.  The Task Force's
 legislative proposals reflect a deep respect for individual autonomy as
 well as concern for the welfare of individuals nearing the end of life.

    Recent proposals to legalize assisted suicide and euthanasia in some
 states would transform the right to decide about medical treatment into a
 far broader right to control the timing and manner of death.  After lengthy
 deliberations, the Task Force unanimously concluded that the dangers of
 such a dramatic change in public policy would far outweigh any possible
 benefits.  In light of the pervasive failure of our health care system to
 treat pain and diagnose and treat depression, legalizing assisted suicide
 and euthanasia would be profoundly dangerous for many individuals who are ill
 and vulnerable.  The risks would be most severe for those who are elderly,
 poor, socially disadvantaged, or without access to good medical care.

    In the course of their research, many Task Force members were particularly
 struck by the degree to which requests for suicide assistance by terminally
 ill patients are correlated with clinical depression or unmanaged pain, both
 of which can ordinarily be treated effectively with current medical
 techniques.  As a society, we can do far more to benefit these patients by
 improving pain relief and palliative care than by changing the law to make
 it easier to commit suicide or to obtain a lethal injection.


   * This report, like much of the current debate, focuses solely on assisted
     suicide and euthanasia by physicians, nurses, or other health care

   * In this report, "assisted suicide" refers to actions by one person to
     contribute to the death of another, by providing medication or a
     prescription or taking other steps.  With assisted suicide, the person
     who dies directly takes his or her own life.  In contrast, "euthanasia"
     refers to direct measures, such as a lethal injection, by one person to
     end another person's life for benevolent motives.  Both practices are
     distinct from the withdrawal or withholding of life-sustaining treatment
     in accord with accepted ethical and medical standards.


   * Contrary to what many believe, the vast majority of individuals who are
     terminally ill or facing severe pain or disability are not suicidal.
     Moreover, terminally ill patients who do desire suicide or euthanasia
     often suffer from a treatable mental disorder, most commonly
     depression.  When these patients receive appropriate treatment for
     depression, they usually abandon the wish to commit suicide.

   * Depression is distinct from the normal feelings of sadness generally
     experienced by terminally ill patients.  It is a myth that major
     clinical depression ordinarily accompanies terminal illness.

   * While thoughts about suicide ("suicidal ideation") are a significant
     risk factor for suicide, many individuals experience suicidal ideation
     but never commit or attempt suicide.  These thoughts can be an important
     and normal component of coping with terminal illness.

   * Uncontrolled pain, particularly when accompanied by feelings of
     hopelessness and untreated depression, is a significant contributing
     factor for suicide and suicidal ideation.  Medications and pain relief
     techniques now make it possible to treat pain effectively for most

   * Despite the fact that effective treatments are available, severely and
     terminally ill patients generally do not receive adequate relief from
     pain.  Studies report that over 50 percent of cancer patients suffer
     from unrelieved pain, even though patients wit h cancer are more likely
     than other patients to receive pain treatment.

   * Numerous barriers contribute to the pervasive inadequacy of pain relief
     and palliative care in current clinical practice, including a lack of
     professional knowledge and training, unjustified fears about physical
     and psychological dependence, poor pain assessment, pharmacy practices,
     and the reluctance of patients and their families to seek pain relief.


   * Under New York law, competent adults have a firmly established right to
     accept or reject medical treatment, including life-sustaining measures.
     Competent adults also have the right to create advance directives for
     treatment decisions, such as a living will or health care proxy, to be
     used in the event they lose the capacity to make medical decisions for

   * New York is one of two states in the nation that does not currently
     permit the withdrawal or withholding of life-sustaining treatment from
     an incapacitated adult patient who has not signed a health care proxy or
     provided clear and convincing evidence of h is or her treatment wishes.
     Legislation proposed by the Task Force, under consideration by the New
     York State Legislature, would permit family members and others close to
     the patient to decide about life-sustaining treatment in these

   * Neither suicide nor attempted suicide is a criminal offense in any
     state.  Like most other states, New York prohibits assisting a suicide.
     Euthanasia is barred by law in every state, including New York.

   * Suicide assistance generally constitutes a form of second-degree
     manslaughter under New York law.  Euthanasia falls under the definition
     of second-degree murder, regardless of whether the person consents to
     being killed.

   * The provision of pain medication is legally acceptable even if it may
     hasten the patient's death, if the medication is intended to alleviate
     pain or severe discomfort, not to cause death, and is provided in accord
     with accepted medical standards.

   * Neither the United States nor the New York State Constitution grants
     individuals a "right" to suicide assistance or euthanasia.  Although the
     right to refuse life-sustaining treatment is constitutionally protected,
     the courts have consistently distinguished the right to refuse
     treatment from a right to commit suicide.  In affirming the right to
     forgo treatment, the courts have recognized the state's legitimate
     interest in preventing suicide.


   * Three general positions about assisted suicide and euthanasia have
     emerged in the ethical and medical literature.  First, some believe that
     both practices are morally wrong and should not be performed.  Others
     hold that assisted suicide or euthanasia are legitimate in rare and
     exceptional cases, but that professional standards and the law should
     not be changed to authorize either practice.  Finally, some argue that
     assisted suicide, or both assisted suicide and euthanasia, should be
     recognized as legally and morally acceptable options in the care of
     dying or severely ill patients.

   * While many individuals do not distinguish between assisted suicide and
     euthanasia on ethical or policy grounds, some find assisted suicide more
     acceptable than euthanasia, either intrinsically or because of
     differences in the social impact and potential h arm of the two



   * The members of the Task Force hold different views about the ethical
     acceptability of assisted suicide and euthanasia.  Despite these
     differences, the Task Force members unanimously recommend that existing
     law should not be changed to permit these practice s.

   * Some of the Task Force members believe that assisted suicide and
     euthanasia are inherently wrong, because the practices violate society's
     long-standing prohibition against ending human life.  These members
     believe that one person should not assist another' s death or kill
     another person, even for benevolent motives.

   * Other Task Force members are most troubled by the prospect of
     medicalizing the practices.  They believe that physician-assisted
     suicide and euthanasia violate values that are fundamental to the
     practice of medicine and the patient-physician relationship.

   * Some Task Force members do not believe that assisted suicide is
     inherently unethical or incompatible with medical practice.  On the
     contrary, they believe that providing a quick, less prolonged death for
     some patients can respect the autonomy of patients and demonstrate care
     and commitment on the part of physicians or other health care
     professionals.  Nonetheless, these members have concluded that
     legalizing assisted suicide would be unwise and dangerous public policy.


   * The Task Force members unanimously concluded that legalizing assisted
     suicide and euthanasia would pose profound risks to many patients.  For
     purposes of public debate, one can describe cases of assisted suicide in
     which all the recommended safeguards would  be satisfied.  But positing
     an "ideal" or "good" case is not sufficient for public policy, if it
     bears little relation to prevalent social and medical practices.

   * No matter how carefully any guidelines are framed, assisted suicide and
     euthanasia will be practiced through the prism of social inequality and
     bias that characterizes the delivery of services in all segments of our
     society, including health care.  The practices will pose the greatest
     risks to those who are poor, elderly, members of a minority group, or
     without access to good medical care.

   * The growing concern about health care costs increases the risks
     presented by legalizing assisted suicide and euthanasia.  This cost
     consciousness will not be diminished, and may well be exacerbated, by
     health care reform.

   * The clinical safeguards that have been proposed to prevent abuse and
     errors would not be realized in many cases.  For example, most doctors
     do not have a long-standing relationship with their patients or
     information about the complex personal factors relevant to evaluating a
     request for suicide assistance or a lethal injection.  In addition,
     neither treatment for pain nor the diagnosis of and treatment for
     depression is widely available in clinical practice.

   * In debating public policies, our society often focuses on dramatic
     individual cases.  With assisted suicide and euthanasia, this approach
     obscures the impact of what it would mean for the state to sanction
     assisted suicide or direct killing under the auspices of the medical

   * From the perspective of good health, many individuals may believe that
     they would opt for suicide or euthanasia rather than endure a vastly
     diminished quality of life.  Yet, once patients are confronted with
     illness, continued life often becomes more precious; given access to
     appropriate relief from pain and other debilitating symptoms, many of
     those who consider suicide during the course of a terminal illness
     abandon their desire for a quicker death in favor of a longer life made
     more tolerable with effective treatment.

   * The Task Force members feel deep compassion for patients in those rare
     cases when pain cannot be alleviated even with aggressive palliative
     care.  They also recognize that the desire for control at life's end is
     widely shared and deeply felt.  As a society, however, we have better
     ways to give people greater control and relief from suffering than by
     legalizing assisted suicide and euthanasia.

   * Depression accompanied by feelings of hopelessness is the strongest
     predictor of suicide for both individuals who are terminally ill and
     those who are not.  Most doctors, however, are not trained to diagnose
     depression, especially in complex cases such as patients who are
     terminally ill.  Even if diagnosed, depression is often not treated.  In
     elderly patients as well as the terminally and chronically ill,
     depression is grossly underdiagnosed and undertreated.

   * The presence of unrelieved pain also increases susceptibility to
     suicide.  The undertreatment of pain is a widespread failure of current
     medical practice, with far-reaching implications for proposals to
     legalize assisted suicide and euthanasia.

   * If assisted suicide and euthanasia are legalized, it will blunt our
     perception of what it means for one individual to assist another to
     commit suicide or to take another person's life.  Over time, as the
     practices are incorporated into the standard arsenal of medical
     treatments, the sense of gravity about the practices would dissipate.

   * The criteria and safeguards that have been proposed for assisted suicide
     and euthanasia would prove elastic in clinical practice and in law.
     Policies limiting suicide to the terminally ill, for example, would be
     inconsistent with the notion that suicide i s a compassionate choice for
     patients who are in pain or suffering.  As long as the policies hinge on
     notions of pain or suffering, they are uncontainable; neither pain nor
     suffering can be gauged objectively, nor are they subject to the kind of
     judgments needed to fashion coherent public policy.  Euthanasia to cover
     those who are incapable of consenting would also be a likely, if not
     inevitable, extension of any policy permitting the practice for those
     who can consent.

   * These concerns are heightened by experience in the Netherlands, where
     the practices have been legally sanctioned.  Although Dutch law requires
     an explicit request for euthanasia by the patient, a national study in
     the Netherlands found that of approximately 3300 deaths annually
     resulting from mercy killing, l,000 deaths from euthanasia occurred
     without an explicit request.  Moreover, in some cases, doctors have
     provided assisted suicide in response to suffering caused solely by
     psychiatric illness, including severe depression.


   * Professional medical standards should recognize the provision of
     effective pain relief and palliative care, including treatment for
     depression or referral for treatment, as a basic obligation all
     physicians owe to their patients.  The legal prohibition age inst
     assisted suicide and euthanasia should also guide professional standards
     of conduct.

   * Physicians should seek their patients' participation in decisions about
     withdrawing or withholding life-sustaining treatment early enough in the
     course of illness to give patients a meaningful opportunity to have
     their wishes and values respected.

   * Health care professionals have a duty to offer effective pain relief and
     symptom palliation to patients when necessary, in accord with sound
     medical judgment and the most advanced approaches available.

   * New York State statutes and regulations should be modified to increase
     the availability of medically necessary analgesic medications, including
     opioids.  This should be done in a balanced manner that acknowledges the
     importance of avoiding drug diversion.  Chapter 8 sets forth specific
     recommendations for legal reform.

   * Physicians, nurses, and patients must be aware that psychological and
     physical dependence on pain medication are distinct phenomena.  Contrary
     to a widely shared misunderstanding, psychological dependence on pain
     medication rarely occurs in terminally ill patients.  While physical
     dependence is more common, proper adjustment of medication can minimize
     negative effects.

   * The provision of appropriate pain relief rarely poses a serious risk of
     respiratory depression.  Moreover, the provision of pain medication is
     ethically and professionally acceptable even when such treatment may
     hasten the patient's death, if the medication is intended to alleviate
     pain and severe discomfort, not to cause death, and is provided in
     accord with accepted medical practice.

   * The education of health care professionals about pain relief and
     palliative care must be improved.  Training in pain relief and
     palliative care should be included in the curriculum of nursing schools,
     medical schools, residencies, and continuing education for health care

   * Hospitals and other health care institutions should explore ways to
     promote effective pain relief and palliative care, and to remove
     existing barriers to such care.

   * Public education is crucial to enhance pain relief practices.  Like many
     health care professionals, patients and families often have an
     exaggerated sense of the risks of pain medication, and are reluctant to
     seek treatment for pain.  Nurses and physicians should create an
     atmosphere that will encourage patients to seek relief of pain.
     Strategies for pain relief should also maximize patients' sense of

   * Insurance companies and others responsible for health care financing
     should promote effective pain and symptom management and address
     barriers that exist for some patients.

   * Health care professionals should be familiar with the characteristics of
     major depression and other common psychiatric illnesses, as well as the
     possibility for treatment.  Major clinical depression is generally
     treatable, and can be treated effectively even in the absence of
     improvement in the underlying disease.  Patients should also receive
     appropriate treatment for less severe depression that often accompanies
     terminal illness.

   * Physicians should create an atmosphere within which patients feel
     comfortable expressing suicidal thoughts.  Discussion with a physician
     or other health care professional about suicide can identify the need
     for treatment and make the patient feel less isolated.  This discussion
     does not prompt suicide; on the contrary, talking with health care
     professionals often decreases the risk of suicide.

   * When a patient requests assisted suicide or euthanasia, a health care
     professional should explore the significance of the request, recognize
     the patient's suffering, and seek to discover the factors leading to the
     request.  These factors may include insufficient symptom control,
     clinical depression, inadequate social support, concern about burdening
     family or others, hopelessness, loss of self-esteem, or fear of

			      INTRODUCTION		       page 1

	  Respect for individual choice and self-determination has
    served as a touchstone for public policies about medical decisions
    over the past two decades.  Designed to promote these values, legal
    reform has wrought many gains, including clear recognition of a
    right to refuse life-sustaining measures.  Social and clinical
    practices, however, have changed more slowly, often leaving patients
    and those close to them without a sense of control over the course
    of treatment.  As a result, the public's fear of a painful death
    prolonged by medical advances has not abated.  This growing public
    concern about control at life's end and the emphasis on individual
    self-determination have brought us to a new crossroads in the realm
    of medical practice and ethics.  For the first time in the United
    States, assisted suicide and euthanasia are issues of serious and
    widespread public consideration.

	  Assisted suicide occurs when one person assists another to
    take his or her own life, either by providing the means to commit
    suicide or by taking other necessary steps.  Euthanasia entails
    direct measures, such as a lethal injection, by one person to end
    another person's life.  Euthanasia may be voluntary, performed with
    the explicit consent of a competent adult, or it can be performed
    without consent, in which case it is usually called "nonvoluntary"
    euthanasia.  Euthanasia provided over the patient's objection is
    generally referred to as "involuntary" euthanasia.  Both assisted
    suicide and euthanasia are distinct from the withdrawal or
    withholding of life-sustaining treatment.(1)

	  While assisted suicide and euthanasia can be offered outside
    the medical context by family members or others, recent debate has
    focused on these practices by physicians and other health care
    professionals.  Assisted suicide in the medical context is usually
    provided by giving a prescription or medications to a patient
    seeking to end his or her life.  A lethal injection would be the
    most common form of euthanasia provided by doctors.


    (1)	  Same use the term "euthanasia" or "passive euthanasia" to
	  include the wrongful or inappropriate withholding or
	  withdrawal of life- sustaining treatment.  This report, like
	  much of the current debate, uses the term "euthanasia" more
	  narrowly, referring only to active measures, such as a lethal
	  injection, to end the patient's life.  The Task Force
	  recognizes that defining the term in this way clarifies its
	  own intentions, but does not address the complex relationship
	  between action, omission and moral culpability.  For a
	  discussion of this issue, see chapter 5, pp. 82-93.

     page 2		    WHEN DEATH IS SOUGHT

	  Several prominent cases have spurred debate about
    physician-assisted suicide and euthanasia.  In 1988, in an anonymous
    article in the Journal of the American Medical Association, a
    physician described how he had given a lethal injection to a young
    woman dying of ovarian cancer.(2) The physician had no prior
    relationship with the patient and had not discussed the decision
    with her.  Instead, he decided to provide the lethal injection based
    on her mumbled words, "Let's get this over with."

	  On June 4, 1993, Dr.  Jack Kevorkian helped Janet Adkins
    commit suicide in a Volkswagen van in a Michigan park.  Janet Adkins
    was 54 years old and still physically active but was experiencing
    the early symptoms of Alzheimer's disease.  Kevorkian used a machine
    he developed that delivered a fatal dose of potassium chloride when
    Janet Adkins pushed a button.  Nineteen other highly publicized
    deaths have followed with Kevorkian's assistance.  Kevorkian has had
    little previous contact with the patients he assists, many of whom,
    like Janet Adkins, were not terminally ill.  A retired pathologist,
    it is likely that he has little or no experience in diagnosing
    depression or treating terminally ill patients.  Although some
    regard Kevorkian as a champion for human rights, he has crystallized
    the doubts of many about the potential for abuse and the dangers of
    physician-assisted suicide.

	  In contrast to Kevorkian, Dr.  Timothy Quill had a
    long-standing relationship with the patient whose death he assisted.
    Writing about the case in the New England Journal of Medicine in
    March 1991, Quill explained that he had offered all available
    medical alternatives to his patient, encouraged her to accept
    treatment for her condition, and spoke with her at length about her
    decision before prescribing the barbiturates that would enable her
    to take her own life.(3)

	  In February 1993, the Netherlands became the first nation to
    establish policies permitting doctors to assist a suicide or to
    perform voluntary euthanasia.  Under Dutch law, physicians cannot be
    prosecuted for either practice if they follow specified guidelines
    and report their actions to the coroner in each case.  Although
    assisted suicide and voluntary euthanasia are both legally
    sanctioned, 85 percent of these cases have been instances of
    euthanasia.  Policies in the Netherlands emerged from growing


    (2)	  "It's Over, Debbie," Journal of the American Medical
	  Association 259 (1988):  272.  It remains unclear whether
	  this anonymous article described a fictitious or an actual

    (3)	  T. E. Quill, "Death and Dignity:  A Case of
	  Individualized Decision Making," New England Journal of
	  Medicine 324 (1991):  691-94.

			      INTRODUCTION		      page 3

    acceptance of the practice by physicians, and the long-standing
    reluctance of prosecutors to enforce the law prohibiting assisted
    suicide and euthanasia.

	  In the United States, legislative referenda to legalize the
    practices have been considered in several states.  In November 1991,
    Washington State voted on a referendum to legalize "physician
    aid-in-dying" -- defined to include both assisted suicide and
    euthanasia.  The referendum failed with 54 percent of the public
    voting against it.  If it had passed, Washington would have become
    the first state in the nation to legalize these activities by
    physicians or others.  In November 1992, voters in California
    defeated a similar referendum by the same narrow margin.  These
    votes will no doubt encourage attempts to legalize assisted suicide
    and euthanasia in other states.  At the same time, publicity about
    Kevorkian and public debate about the practices have prompted other
    states to strengthen or clarify their laws prohibiting assisted
    suicide.  Four states, including Michigan, enacted laws in 1993 to
    achieve this goal.(4)

	  Like the referenda in Washington and California, public
    opinion polls suggest that the public in the United States is
    divided on the question of legalizing assisted suicide and
    euthanasia.  The widespread success of the book Final Exit, a how-to
    on committing suicide, left no doubt, however, that some segment of
    the public is deeply concerned about the dying process.(5) A best
    seller for many months, the book tapped into a well-spring of
    anxiety about the loss of control at life's end.  The book's
    popularity is a clarion call, signaling that existing social and
    clinical practices do not give Americans the sense of control they

	  The need to make decisions about the dying process and the
    failure to manage technological advances more wisely has also
    profoundly influenced some segments of the medical profession.  For


    (4)	  Under the Michigan law, the statutory prohibition on
	  assisted suicide will expire no later than December 31, 1994.
	  The law established a commission to study the issue and
	  recommend whether the prohibition should be continued,
	  modified, or abandoned.

    (5)	  The full title of the book is Final Exit:  The
	  Practicalities of Self-Deliverance and Assisted Suicide for
	  the Dying.  It was written by Derek Humphrey, the founder of
	  the Hemlock Society.  A study reported in the New England
	  Journal of Medicine about the book's impact concluded that,
	  although the overall suicide rate in New York City had not
	  changed following the book's publication, suicide by
	  asphyxiation using a plastic bag, one of the methods
	  recommended in the book, had increased.  Of the 15
	  individuals reported to have used the book to commit suicide,
	  most were not terminally ill and six had no history of
	  medical illness or diagnosed illness at autopsy.  P. M.
	  Marzuk et al., "Increase in Suicide by Asphyxiation in New
	  York City After the Publication of Final Exit," New England
	  Journal of Medicine 329 (1993):  1508-10.

    page 4		     WHEN DEATH IS SOUGHT

    physicians, decisions to withhold or to stop treatment, calling for
    their intervention in the timing and manner of death, have become
    routine.  While earlier generations of physicians were trained to
    stave off death whenever possible and had few available means at
    their disposal to do so, physicians today, especially those who are
    younger, have grown accustomed to the idea that life inappropriately
    prolonged can also be a defeat for them and for their patients.

	  The medical community, like the broader society, has therefore
    reached a crossroads, with some physicians advocating legal change
    that would permit them to assist their patients to commit suicide
    under certain circumstances.  Despite the fact that assisted suicide
    is illegal in most states and euthanasia is prohibited throughout
    the United States, press reports and polls suggest that some
    physicians already respond to their patients' requests for help by
    prescribing medication or providing a lethal injection.  The
    practice occurs in the private relationship between doctor and
    patient, yielding little public information about the frequency or
    circumstances of medically assisted suicide or euthanasia.

	  In New York State, no serious effort to legalize assisted
    suicide or euthanasia is underway.  New York's criminal law
    prohibits both practices.(6) The health care proxy law, enacted in
    1990 to give adults an effective way to exercise the right to decide
    about treatment, including life-sustaining measures, explicitly
    states that it is not designed to permit or promote assisted suicide
    or euthanasia.(7) Pending legislation proposed by the Task Force,
    which would allow family members and others close to the patient to
    decide about treatment for incapacitated patients who have not
    signed health care proxies, contains a similar statement.(8) Hence,
    like the law in states across the country, New York law to date has
    consistently distinguished decisions to forgo life-sustaining
    treatment from assisted suicide and euthanasia.

	  The issue of assisted suicide has been posed most directly in
    New York State by the case involving Dr.  Timothy Quill.  A resident
    of Rochester, New York, Quill faced potential criminal and
    professional sanctions following publication of his article in the
    New England Journal of Medicine.  A grand jury was convened in
    Rochester and decided not to indict him.  Likewise, the State Board
    for Professional Medical Conduct considered the case and chose not


    (6)	  N.Y.  Penal law  120.30,120.35,12,5.15(3),12,5.25(l)
	  (McVinney 1987).  See chapter 4 for discussion of New York

    (7)	  N.Y. Public Health law, Sec. 2989(3) (McKinney 1993).

    (8)	  New York State Assembly Bill No. 7166, Sec. 2995-q(3) (1994).

			      INTRODUCTION		      page 5

    to pursue professional misconduct charges.  Writing for the board, a
    three member panel concluded that Quill could not have known with
    certainty that his patient would use the medication he prescribed
    for insomnia to kill herself.  In its opinion in the Quill case, the
    board recognized the important moral and social issues presented by
    the case and asked the Task Force on Life and the Law to provide
    guidance for policies in New York State.  The Task Force agreed to
    deliberate about assisted suicide and euthanasia not because of the
    Quill case itself, but because the case struck a public nerve,
    echoing broad public concern about the practices.

	  This report reflects the Task Force's exploration of medically
    assisted suicide and euthanasia.  It examines the clinical, legal,
    and social context for the current debate about the practices.
    Presented in the first half of the report, that information includes
    important insight about the problem of suicide generally, the
    reasons that people commit suicide, the capacity of medicine to
    respond to some of those underlying reasons, and its widespread
    failure to do so.  Chapter Four examines in-depth the law on
    assisted suicide and euthanasia and the relationship of that body of
    law to prevailing medical standards.  The chapter also discusses
    whether there is a constitutional right to suicide assistance and
    euthanasia.  Chapter Five sketches the current debate about assisted
    suicide and euthanasia, exploring the ethical arguments set forth by
    those who advocate legalizing assisted suicide and euthanasia as
    well as by those who firmly oppose any such legal change.

	  The second half of the report presents the Task Force's
    recommendations for public policy.  Those recommendations first
    address whether the law should be changed to permit assisted suicide
    and euthanasia.  The report also describes the principles that
    should animate professional medical standards.  In the final
    chapter, the report proposes policies to enhance the treatment
    provided to dying and incurably ill patients.  The debate about
    assisted suicide and euthanasia has forced a reexamination of the
    care provided to terminally and chronically ill individuals; it has
    highlighted pervasive shortcomings in the clinical response to pain,
    to suffering arising from treatable causes such as clinical
    depression, and to requests for suicide assistance.  The final
    chapter of the report proposes specific statutory and regulatory
    steps to improve access to pain relief, and provides recommendations
    for clinical practice.


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