A brief case against euthanasia and physician assisted suicide

Opposition to euthanasia (or physician assisted suicide – I count these together in this article though they have important differences) can seem extremely counterintuitive at a very superficial level. We put dogs down when they suffer – why do we treat humans worse than dogs? Why do we cruelly force people to continue living when they desperately wish to die? In this short piece I will try to summarise the main reasons why people oppose euthanasia. There is much more that could be said – this is intended only to be a short piece summarising the main reasons.

Some reasons to oppose euthanasia are inherent moral reasons to oppose it: reasons to think euthanasia is inherently wrong. Other reasons are practical reasons which concede that even if euthanasia is not morally wrong in itself, legalising euthanasia would, on balance, be bad for a variety of reasons. It is helpful to be aware of this difference – you can think that euthanasia is not wrong while still opposing the legalisation of it for pragmatic reasons and the effect it would have on society more generally.

Arguments against euthanasia

So why should people oppose the legalisation of euthanasia? In no particular order:

1 Conscientious objection

It would likely be included as part of medical care with an expectation for healthcare professionals including doctors to actively participate or refer onwards[1], which would be a considerable conscience violation. Given that only ¼ of physicians would be prepared to participate themselves[2], this is a substantial concern.

2 The psychological impact on healthcare professionals

Performing euthanasia can take a considerable psychological toll on doctors, as the evidence from Holland and the US has shown[3].

3 The opposition of palliative care specialists

The overwhelming majority of palliative specialists in the UK oppose the legalisation of PAS[4]. These are the experts in end of life care and they overwhelmingly disagree that there is a need for euthanasia as opposed to good quality palliative care.

4 The disincentivisation of palliative care

Euthanasia/PAS disincentivise palliative care both societally and individually. Holland’s palliative care has been widely criticised[5], while the UK has been at the forefront of palliative advances precisely because we opted to develop palliative care. It is even common for patients in Holland to ask for euthanasia because of a fear of poor palliative care[6].

With the economic arguments in favour of euthanasia, it is extremely difficult to believe that economic considerations would not exert themselves with considerable force, even if they are not the initial motivation for legalising euthanasia/PAS. Ageing populations require vastly increased welfare expenditure[7], and the healthcare expenditure alone in the last year of life is disproportionately high[8].

Given that we already see hints of economic thinking in quality of life discussions at present, it is easy to see how those economic considerations would be transposed to deciding on whether to euthanise someone. As Baroness Warnock, one of the UK’s leading bioethicists in the last century, chillingly put it, ‘If you’re demented, you’re wasting people’s lives – your family’s lives – and you’re wasting the resources of the National Health Service… if somebody absolutely, desperately wants to die because they’re a burden to their family, or the state, then I think they too should be allowed to die… …there’s nothing wrong with feeling you ought to do so for the sake of others as well as yourself.’[9]

This has been seen on the individual level too. We have already seen cases of patients being refused treatment while being offered euthanasia instead, for reasons of cost[10] – several people in Oregon each year opt for PAS for financial reasons[11].

Palliative care is thereby disincentivised both in its development (why develop better palliative care if people are opting to die instead?) and in its implementation (it will be financially limited, and healthcare professionals will also be more inclined to learn about the easier way out rather than all the complex details of palliative care).

5 The increase in suicide rates

Legalising EPAS increases suicide rates more generally: Jones and Paton showed it is associated with a 6-12% increase in the total number of suicides, particularly affecting vulnerable groups such as women and the elderly[12]. The EPAS rates in Holland, Belgium, Oregon, etc., are far higher than the rate of people going abroad from the UK, and there appears to be very little evidence that a large number of people in the UK want to be euthanised – certainly nothing approaching the rates abroad[13].

6 Pressure on the vulnerable

This is part of a wider concern that legalising EPAS puts substantial pressure on vulnerable people to end their lives. Studies from Oregon have shown that since legalisation of PAS, the number of people undergoing PAS for the reason that they feel they are a burden to their family/friends has gone up dramatically, from 2 in the first year and 8 in the second year to 91 in 2018[14].

It is for this reason (among others) that Lord Sumption of the UK Supreme Court, when reviewing the evidence from other countries, found much evidence that this pressure existed, was significant, and was aggravated by negative attitudes to old age and disability[15].

There are people who are particularly vulnerable to a particularly malicious form of pressure: a majority of elder abuse is perpetrated by family members[16], and pressure on doctors from family members to euthanise their relatives is reasonably well documented[17]. It is difficult to work out safeguards preventing families (or others) from encouraging EPAS in the hope of financial gain.

7 The slippery slope

There are many reasons to suppose that a number of slippery slopes will eventuate: the slippery slope from PAS to euthanasia, from adults to children and infants, from voluntary to involuntary euthanasia, and from terminal physical illness to chronic and mental illness or even healthy patients. The reasons are:

    1. That is exactly what has happened in other countries – despite the fact that these countries initially had very restrictive conditions and would have opposed the slippery slope from the start as well[18]. See below for the evidence from other countries.
    2. Slippery slopes are pretty standard when a major shift in bioethical thinking and policy occurs. Abortion is an excellent example – when abortion was legalised in 1967, it was with the sentiment that abortion was still wrong and a bad state of affairs – legalising it was just the lesser of two evils[19]. Abortion is now seen as entirely normal, and even a part of basic healthcare. When it was warned that the clause which allowed abortion up to birth for disability could also include minor ailments like cleft palate, Lord Steel himself said that this idea was ‘totally discreditable’, and Harriet Harman said that the legal scholars making the claim should be reported to the Law Society or Bar Council. Frank Doran MP called it ‘pure scaremongering’. We were told by Warnock and Steel that this clause existed only for children who were ‘incapable of living any meaningful life’. In fact, we now have several abortions for cleft palate under this clause each year, and many hundreds for Down Syndrome. We were told by Lord Brightman that the abortion of viable babies was unthinkable – ‘a doctor does not need an Act of Parliament to teach him that elementary duty [to try and deliver the child alive]’. He and Warnock claimed there was no need to mandate doctors to take ‘reasonable steps to secure that the child is born alive’[20]. In fact, now we have several hundred abortions for babies after 22 weeks every year (and hundreds more in the weeks leading up to 22 weeks)[21]. Doctors and other healthcare professionals were initially given substantial conscience protections. We now have burdens on doctors to refer patients for abortions against their conscience and even when there is no clinical indication[22], we have considerable pressure on healthcare professionals to actually perform abortions (become reality in other countries[23]), and we have imposed duties on healthcare professionals to be involved in facilitating abortions against their conscience as long as they are not actively participating in the operating room itself[24]. Finally, we had probably at most 10,000 abortions a year before abortion was legalised[25]. We now have over 200,000 a year in the UK[26].
    3. Once the gates have been opened to doctors killing their patients, it is difficult to see how economic pressures would not impose themselves. There are very powerful economic arguments for expanding the scope and practice of euthanasia once we allow it in some forms.
    4. More generally, the powerful reasons in favour of euthanasia are precisely why it is so dangerous – the fact that autonomy, compassion and economic arguments have so much power is precisely why a slippery slope is so plausible.
    5. The arguments for euthanasia themselves logically lead to considerable expansion. If autonomy is the driving motivation, then why should we impose any limits on euthanasia other than consent? If children or healthy adults or adults with eating disorders want to end their lives, who are we to get in the way of their autonomy? Likewise, if compassion is the driving motivation, it is difficult to see why we should impose any limits at all, even the requirement for a voluntary decision. As we will see below, these limits have been expanding in countries which have introduced EPAS, including extending EPAS to patients without their consent (sometimes with capacity, sometimes without)[27].
    6. A slippery slope is precisely what campaigners want – they have stated their ambition to introduce more widespread EPAS than initially proposed[28].
    7. Doctors are too under-resourced (especially in the UK) to do due diligence to the scope, level and quality of assessment needed to ensure that people meet the criteria for EPAS. There is simply no way doctors will be able to look at all the evidence that people are making the decision voluntarily, for example, even if doctors did have special training to ensure this. As an aside, those in Holland and other countries who have been tasked with this have spectacularly failed to ensure that patients meet the requirements before authorising their deaths – even when panels were set up who had the specific job of checking these cases[29]. Professor John Griffiths, perhaps the leading defender of Dutch euthanasia, commented that the results of the first two government surveys were, ‘as far as the effectiveness of control is concerned… pretty devastating.'[30] Professor Henk Leenen, described by The Lancet as ‘the guiding hand behind legislation in the Netherlands on euthanasia’, said as far back as 1990 that there was an ‘almost total lack of control on the administration of euthanasia’ in the country.[31]
    8. More generally, it is impossible to regulate the practice in these ways. The failings in other countries have been profound and have proven difficult to remedy (see below)[32].

8 The failure of euthanasia in other countries

The experience of other countries has been horrendous – even though these countries initially introduced EPAS in highly restrictive legal contexts. Take Holland, for example. In Holland, the 1995 review of euthanasia cases showed 135,500 deaths in the year, 3,200 of which were voluntary euthanasia, with another 400 PAS. In addition to this, there were 900 cases of involuntary and non-voluntary euthanasia, many of whom were competent patients who had not expressed a wish to die. These cases of what most of us in the UK would deem to be murder were treated with absolute impunity. In addition, there were 90 cases of euthanasia for newborn babies with disabilities (mainly spina bifida). There were also 14,200 cases of involuntary passive euthanasia – people killed by the withdrawal of treatment without their consent, with the intention of shortening the patient’s life[33]. These are huge numbers for such a small population and are profoundly worrying. Now euthanasia accounts for 4% of all deaths in Holland, but this proportion goes up hugely when including the more recent phenomenon of terminal sedation, where patients are sedated and then starved/dehydrated to death, often with the intention of shortening life. This alone accounts for 12-18% of all deaths in Holland, and has been devised to work around the few legal restrictions that do remain[34]. In Holland there are also now attempts to formally legalise euthanasia for those who are entirely healthy but simply ‘tired of life’[35]. There is already euthanasia for patients with depression and eating disorders[36]. Virtually every legal safeguard has been removed in the country over time. Remarkably, a top bioethicist defended the non-voluntary euthanasia in Holland (which he claimed constituted a substantial 40% of cases) by saying that it was voluntary because the family and doctors had chosen it – a bizarre inversion of the concept of voluntariness[37]. There are similar issues in other countries such as Belgium. In Belgium, for example, euthanasia without consent has been responsible for between 1.7-3.2% of all deaths, and even over 5% of all deaths in some regions[38], 50% of euthanasia nurses have been involved in cases where the patient did not consent[39], and 50% of all cases are entirely unreported[40]. Children of any age can be euthanised – this was even happening when it was illegal because of the cultural changes from legalising EPAS[41]. Organ donation from euthanasia in children is also permitted in both countries[42]. In Holland, euthanising newborn babies – usually because they have spina bifida – is reasonably common, to the number of around 100 each year[43].

Arguably, the most alarming part of all this is the lack of regulation and persistent illegal forms of euthanasia to which the state turns a blind eye. The examples are too many for this short post, but we have already seen that half of cases in Belgium are not even reported, despite the legal mandate. A particularly revealing example, though, is the case of Dutch GP, Dr van Oijen, who was one of the pitiful number people to actually be investigated for widespread illegal euthanasia, was actually convicted of murder, because he breached every single one of the key guidelines. There was no explicit request – in fact, the patient had declared that she did not want to die; there was not unbearable suffering (she was comatose at the time); there was no consultation with another physician; the drug had exceeded its expiration date after being left over from euthanising a previous patient; and he lied when reporting the death, saying it was by natural causes. Dr van Oijen was given a short suspended jail sentence, a suspended fine (because he lied on the report), and was given only a warning by the medical authorities[44].

Given breaches of regulations are so widespread (including lack of reporting, non-voluntary euthanasia, etc.), this is only the tip of the iceberg. But there are so few investigations for breaches in Holland (despite the known large number) that details of individual cases emerge only from time to time. There are far more details of the lack of regulation to be found in John Keown’s book (see references).

Indeed, the state of EPAS in Holland, Belgium and elsewhere, has filled volumes of books, and though I would like to repeat much of it here, I can only repeat a small bit. But it is worth closing this section with some comments from the United Nations Human Rights Committee – certainly no adamant pro-lifers:

“The Committee learnt with unease that under the present legal system more than 2,000 cases of euthanasia and assisted suicide (or a combination of both) were reported to the review committee in the year 2000 and that the review committee came to a negative assessment only in three cases. The large numbers involved raise doubts whether the present system is only being used in extreme cases in which all the substantive conditions are scrupulously maintained…

The Committee considers it difficult to reconcile a reasoned decision to terminate life with the evolving and maturing capacities of minors…

The Committee is gravely concerned at reports that newborn handicapped infants have had their lives ended by medical personnel. The State Party should scrupulously investigate any such allegations of violations of the right to life (article 6 of the Covenant), which fall outside the law…”[45]

This has not been assuaged. A more recent HRC report reiterated that ‘The Committee remains concerned at the extent of euthanasia and assisted suicides in the State Party’, noting that the lack of need for judicial review was a significant problem.

9 The inviolability of human rights

Our basic human rights are inviolable such that we are not even entitled to abdicate them ourselves. Take, for example, the right not to be enslaved, as enshrined in the ICCPR[46]. Most people are agreed that we do not have a right to sell ourselves into slavery as chattel slaves – to do so would be to degrade ourselves and disrespect our own humanity, as well as to set an unacceptable precedent for how human beings may permissibly be treated. Likewise, since the right to life is the most basic right, it is reasonable to suppose that we may not violate our own right to life.

10 The intrinsic value of life

Life has intrinsic value – this is the only way to explain human equality. Humans are equal regardless of their ‘quality of life’ or capacities, and most of us (for now – but not in Holland, etc.) are agreed that involuntary euthanasia on the grounds of disability is wrong. But if the value and dignity of our lives is not based on quality of life or capacities, then the ultimate value of human life must be intrinsic, not instrumental. If so, then it is hard to see how that value could be overridden by essentially disability considerations.

11 The inegalitarian infrastructure of euthanasia logic

This reflects the deeply inegalitarian intellectual infrastructure of the euthanasia advocacy movement. It is difficult to separate euthanasia advocacy from inegalitarian thinking. This is reflected most clearly in the history of the euthanasia movement: in the ancient world it was performed routinely on disabled and female infants, and when the movement renewed in the modern world it was primarily centred around the euthanising of mentally disabled people and other eugenic ideas. This is why it was such a central part of the Nazi movement – and was rejected soundly after World War 2 because of these links. For more on the history of the euthanasia movement, see my lecture here: https://www.youtube.com/watch?v=SGDAeF-UCcU&feature=emb_title

12 The inconsistency of moderate euthanasia laws and egalitarianism

Any ‘moderate’ euthanasia law that allows euthanasia in some cases but not others (as most advocates propose) will likely have the implication that some lives are worth less than others. But this is deeply inegalitarian. It will likely facilitate a cultural shift that will be reflected through our treatment of disabled people in other spheres of society.

In short, to sum up the last few points, our foundations for human equality and dignity are more deeply tied to notions of intrinsic value than we might have thought, and more fragile/accidental too.

13 The existential – not pain-filled – crises behind euthanasia

Surveys show that primary problems driving EPAS are existential – a lack of autonomy, dignity, etc[48]. These are not ultimately medical problems, but to give up on patients rather than trying to find solutions to these problems is not only not honouring our duties to vulnerable people suffering existential crises, but also to disincentivise the more general search for solutions for these widespread problems.

Arguments for euthanasia

To briefly respond to the arguments for euthanasia:

Autonomy

This is clearly a powerful argument for those of us living in a society which puts a premium on autonomy. But there are a number of concerns here:

  • It is not frequently explained why autonomy has such a central position in our moral discourse, or what its value consists in. Certainly, it is difficult to see why it should be the foremost moral consideration above all others. And it is not obvious that the general liberal emphasis on autonomy over the last century or two has led to considerably happier or more flourishing societies – on the contrary, it seems to have contributed to a general lack of sense of meaning in life and life satisfaction in the West.
  • There is a question about whether autonomy should override other values. If it does, then it is hard to see why euthanasia should be limited at all – any one, even healthy young children should be able to opt for it, or people with eating disorders, or people ‘tired of life’. If it does not, then the argument from ‘autonomy’ to legalising euthanasia is far from clear.
  • Legalising euthanasia may (though this is far from clear too) facilitate the autonomy of some individuals opting for euthanasia, but it may at the same time limit the autonomy of many others. This is made much clearer by the aforementioned evidence that there is considerable pressure put on others to undergo EPAS once EPAS is legalised – and it seems like these numbers are far larger than the number of people whose autonomy might be facilitated by legalisation. And it certainly does not facilitate the autonomy of the many thousands of people who are involuntarily or non-voluntarily euthanised in jurisdictions which have liberalised EPAS laws.
  • It is questionable whether legalising EPAS even facilitates the autonomy of those undergoing euthanasia, for the reasons described in the last point. It is a myth that legalisation is the only impediment to autonomy and that legalising something automatically gives someone a significantly freer choice whether or not to pursue it. We are simply subject to far too many and diverse pressures as humans for this to be plausible, especially in the case of euthanasia.
  • We often limit autonomy, either to prevent harm to others (see point 3 in this section) or even to prevent indignity to oneself. There are many things we prohibit people from doing to themselves (and enlisting others to help) precisely because we think that they should not be allowed to harm themselves in such ways: for example, female genital mutilation, dwarf throwing for entertainment, slavery, elective limb amputation, duelling, driving without a seatbelt, and gay conversion therapy are all illegal (or thought should be illegal) even when consented to.
  • Almost every euthanasia advocate does, in fact, put limits on autonomy in the case of euthanasia: as when they limit it to people who are terminally ill, or chronically ill, for example. So there is a tacit concession already that autonomy is not an overriding value.

Compassion

Again, it is immediately obvious why someone would intuit that allowing EPAS is the compassionate, and therefore the right, thing to do. This instinct is entirely natural and understandable. However:

  • If EPAS is allowed on these grounds, it is again difficult to see how it should have any limits such as those described above. In particular, it is difficult to see why it should be limited to adults, or even to those who consent. This is, of course, why involuntary euthanasia of adults and children is so common in places like Holland.
  • Not everything motivated by compassion is genuinely compassionate – 80-90% of foetuses diagnosed with Down Syndrome are aborted in the UK[49], often on the grounds that it is the compassionate thing to do. But studies suggest that 99% of people with Down Syndrome are happy with their lives[50], such that it is obviously not compassionate to end such people’s lives before their birth. Likewise, as with the previous examples (point 5 in the autonomy section), there are many things which may be compassionate to allow in the sense that someone may sincerely and desperately desire them, but which are not ultimately compassionate because they violate the basic respect due to human persons. In short, not all relieving of desperate desires is compassionate.
  • Compassion is possible without helping someone to commit suicide. We normally accept this in the case of depressed or otherwise suicidal patients – we agree that the most compassionate thing to do is to do our very best to relieve them of their suffering without killing them.
  • Most EPAS is not performed for reasons of pain[51] – as described before, the primary driving factors are existential. It is not compassionate to give up on the alleviation of these factors either individually or societally.
  • It is not compassionate to allow EPAS for the many reasons I gave at the start of this post: it is not compassionate to disincentivise palliative care, to expose thousands of vulnerable people to unwanted pressure to end their lives, to advance the slippery slope of EPAS, to violate the most basic rights of human beings (even with their consent), to express the view in law that some lives are worth more than others and thereby dive into inegalitarian thinking, or to give up the principle of the intrinsic value of life. EPAS may certainly be motivated by good, compassionate intentions, and it may of course relieve some people of some very desperate feelings, but that does not suffice to render it the most compassionate policy option, all things considered.

Thanks very much to anyone who had the patience to read through all this. References are available on request, though I highly recommend John Keown’s Cambridge University Press book ‘Euthanasia, Ethics and Public Policy’ and John Wyatt’s ‘Right to Die?’ to anyone interested.

References

  1. See GMC guidance on conscientious objection: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
  2. See RCP poll, page 3. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
  3. See Kenneth Stevens’ paper here: https://www.tandfonline.com/doi/abs/10.1080/20508549.2006.11877782
  4. See RCP poll, page 2. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
  5. See John Keown’s Cambridge University Press book ‘Euthanasia, Ethics and Public Policy: An Argument Against Legalisation’, 119-120.
  6. Keown, 234-235.
  7. See e.g. the brief parliamentary report at https://www.parliament.uk/business/publications/research/key-issues-for-the-new-parliament/value-for-money-in-public-services/the-ageing-population/.
  8. See Aldrige and Kelley’s paper here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4638261/
  9. Warnock’s comments are available here: https://www.telegraph.co.uk/news/uknews/2983652/Baroness-Warnock-Dementia-sufferers-may-have-a-duty-to-die.html
  10. See, for example, the case of Barbara Wagner: https://abcnews.go.com/Health/story?id=5517492
  11. See the official Oregon report: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year20.pdf
  12. See Jones’ and Paton’s paper here: https://www.ncbi.nlm.nih.gov/pubmed/26437189
  13. In 2014, those travelling to Switzerland from the UK numbered 126 (https://www.theguardian.com/society/2014/aug/20/one-in-five-visitors-swiss-suicide-clinics-britain-uk-germany), while many thousands are legalised every year in Holland and Belgium – despite vastly smaller populations.
  14. All the data for Oregon is available at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx
  15. See the Supreme Court judgment, page 83: https://www.supremecourt.uk/cases/docs/uksc-2013-0235-judgment.pdf
  16. See the National Center on Elder Abuse’s summary here: https://ncea.acl.gov/What-We-Do/Research/Statistics-and-Data.aspx#perpetrators
  17. Keown, 235.
  18. See all of Keown’s book for  a lengthy, detailed exposition of the experiences in Holland, Belgium, the US, Canada, and Australia.
  19. See the comments from David Steel here: https://www.theguardian.com/uk/2007/oct/24/politics.topstories3
  20. See Finnis on all these claims: https://www.telegraph.co.uk/comment/personal-view/3599848/We-warned-them-they-mocked-us-now-weve-been-proved-right.html
  21. See table 5: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/808560/2018_Abortion_Statistics_-_Data_tables__1_.ods
  22. See GMC guidance again: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/personal-beliefs-and-medical-practice/personal-beliefs-and-medical-practice#paragraph-8
  23. See, for example, the recent case in the US: https://www.bbc.com/news/world-us-canada-49515372
  24. See the recent Supreme Court case: https://www.supremecourt.uk/cases/docs/uksc-2013-0124-judgment.pdf
  25. See the BMJ editorial: https://www.bmj.com/content/359/bmj.j5278
  26. See table 1: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/808560/2018_Abortion_Statistics_-_Data_tables__1_.ods
  27. See Keown’s book for great detail on this.
  28. See, for example, Dying With Dignity Canada’s vision: ‘All Canadians have the right to choose their good death’: https://www.dyingwithdignity.ca/strategic_plan
  29. See Keown, chapter 14 and passim.
  30. Keown, 143.
  31. Keown, 151.
  32. Again, see Keown, passim.
  33. See Keown, chapter 11 for all of these statistics
  34. Keown, 188-193.
  35. See, for example: https://www.ncbi.nlm.nih.gov/pubmed/29395542
  36. See John Wyatt’s ‘Right to Die?’, 37-39.
  37. See Robert Young’s SEP contribution: https://plato.stanford.edu/entries/euthanasia-voluntary
  38. See Cohen-Almagor’s JME paper: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2614587
  39. See Inghelbrecht et al.: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2882450/
  40. Cohen-Almagor, ibid.
  41. See Raus: https://link.springer.com/article/10.1007%2Fs11673-016-9705-5
  42. See Bollen et al.: https://adc.bmj.com/content/104/9/827
  43. Keown, 138-139.
  44. Keown, 163-164.
  45. See the UNHRC report, page 78: http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=dtYoAzPhJ4NMy4Lu1TOebEPcGQ%2BYYGAQfcsLRzRFogZ74bJjVjU5%2B6UTfECS2iq5hzy3uM2EQhsQfT5sTAP9UuCzOa42RrEgD7trRpL98nMEmbGo%2FTZJpMPZRRApJzcB4MvhsQemKiGDZXAxmc3Ngg%3D%3D
  46. See the UNHRC report, page 69: http://docstore.ohchr.org/SelfServices/FilesHandler.ashx?enc=dtYoAzPhJ4NMy4Lu1TOebFtU5BqeqKxX7regwxwKT5%2BLP6%2BVtuZTsZ5bmD4iSHPoUvgJYSKOEgGobXs9cXzHtj2gBlQb2hL6lwVIu%2B5N21MBPNQrXIXL%2FOS5XFXqBojQnGM40yDy%2FyJkjfd3CyE3DQ%3D%3D
  47. See article 8: https://www.ohchr.org/Documents/ProfessionalInterest/ccpr.pdf
  48. See, for example, the data for Oregon: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx
  49. See: https://www.thejournal.ie/factcheck-babies-abortion-3823611-Feb2018/
  50. See Skotko et al.: https://www.ncbi.nlm.nih.gov/pubmed/21910246
  51. See, for example, the data for Oregon: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx

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