Elderly Suicide vs. Death With Dignity: Everything You Should Know
Few topics reveal as much about our fears, beliefs, values, and sense of humanity as this one. Elderly suicide has an enormous impact on the families and friends of seniors who take their own lives prematurely. That's why it deserves our attention. How many heartbreaking tragedies might we prevent if we simply knew what to look for and how to take action?
Yet, our feelings about this complex and sensitive issue are often influenced by cultural biases, misconceptions, and the language we use when talking about it. As a result, many of us have conflicted feelings about the controversial issues of euthanasia and death with dignity, sometimes overlooking the factors that make them different than traditional notions of suicide. In fact, surveys have shown that our opinions about such matters can depend a lot on how those topics are framed.1
This article will help you better understand the issues surrounding suicide and physician-assisted dying among older adults. That way, you can better support your elderly friends and loved ones—or find the help you may desperately need to obtain your own peace of mind.
The following information is not a substitute for professional advice from qualified medical, legal, or mental health experts.
Suicide vs. Euthanasia vs. Death With Dignity: How They Differ
The words we use matter—often more than we realize. In relation to this topic, they are especially important. That's because they evoke strong feelings, and they are associated with entirely different contexts and situations.
The distinctions may seem subtle, but they have a large significance in the personal lives of those they impact. So although it's easy to find examples of the following terms being used loosely or interchangeably, many people believe that it behooves all of us to use them within their appropriate contexts.
Here's what you should understand:
Suicide, according to the simplest definition, is the act of intentionally killing yourself. Although many different factors can converge to motivate people to commit suicide, mood disorders such as depression are usually the biggest driving forces in that outcome.2
Unable to effectively cope with their despair, people eventually lose all hope and view suicide as their last remaining option. But although suicide seems like a logical choice to them, studies have shown that people with depression who have recently attempted suicide tend to exhibit cognitive impairments related to their memory, attention, and quality of decision-making.3
That's why suicide is generally considered a tragic result of untreated or poorly treated mental illness. Lacking appropriate support, those attempting suicide often feel powerless to choose any other course of action. Suicide can also have lasting and traumatic effects on the friends and loved ones left behind.
Euthanasia (also known as mercy killing) is the intentional act of painlessly causing the death of someone who is in an irreversible coma or suffering unbearably from a painful and incurable medical condition. The action, where legally carried out, is usually performed by a physician or other health care professional when reasonable alternatives or expectations for improvement are absent. But there are different types of euthanasia: active and passive, which can each be either voluntary or non-voluntary.
Some people also use the term "involuntary euthanasia" to describe an action that is, essentially, murder. Under this scenario, the patient may have been capable of providing consent, but he or she wasn't given the opportunity. Or the patient may have stated a desire to live, but he or she was killed anyway. Either way, the patient's best interests were not put first—taking the action out of the domain of euthanasia and into the realm of something much more sinister.
Death with dignity gives some terminally ill people the option of legally hastening their own death with the assistance of a licensed physician. But death with dignity laws vary between the relatively few regions where they've been enacted. In Canada, for instance, the law makes it possible for a medical provider to perform voluntary euthanasia for certain kinds of patients, although the preferred term for it is medical aid in dying.
In the states where it is legal in the U.S., the typical death with dignity definition excludes any form of euthanasia. So, in those regions, the difference between euthanasia and death with dignity is that, with the latter form of dying, patients themselves must administer the lethal medication. Licensed physicians prescribe the lethal substances for their patients to self-administer once all the steps in a mandatory process have been followed.
In addition to medical aid in dying, death with dignity is also known as:
- Physician aid in dying
- Medical assistance in dying
- Physician-assisted dying
- Physician-assisted death
Of course, you are also likely to run across terms such as "assisted suicide," "doctor-assisted suicide," or "suicide with dignity" when reading about this issue. But to many of the terminally ill seniors who choose the path of dying with dignity, terms that include "suicide" are inaccurate and disrespectful. Their friends and family members also frequently find such terms to be offensive.
After all, "suicide" tends to carry negative connotations of emotional despair, impaired judgment, and immorality. But those who choose to die with dignity are required to be of sound mind. And they get the comfort of knowing that they do not have to experience unbearable agony, an unacceptable quality of life, or an unpeaceful death. In a sense, they do not see themselves as the ones causing their death; that blame falls on their terminal illness. Rather, they are merely decreasing the amount of time that they must suffer. They will die soon anyway.
That's the meaning of death with dignity: being able to exercise your right to die a peaceful death when your fatal illness cannot be cured and you still have the freedom and capability to make such a decision. It's a personal choice that's exercised by rational people of legal age, from young adults to the elderly. "Assisted suicide," in their view, doesn't accurately describe the legal, medical, and conceptual choice they're making.
Still, whether you're talking about death with dignity or euthanasia, debate swirls around this topic. So it's only by understanding the arguments for and against dying with dignity that you can truly appreciate what it all means for the patients, loved ones, physicians, and caregivers impacted by it.
Elderly Suicide Facts and Statistics
As a culture, we tend to think of suicide as primarily occurring among young individuals. Many people also view suicide in the elderly population as somehow being less tragic than youth suicide. Some people even believe, mistakenly, that depression is a normal part of aging or, on the flip side, that seniors are able to cope much better with life's stressors than younger adults. Unfortunately, those beliefs cause too many of us to overlook the very real and widespread problem of suicide among older adults.
In fact, according to the most recent data on suicide rates, elderly men over 75 kill themselves at the highest rate of any age group in the U.S. (39.7 deaths per 100,000 people). And although older women have much lower rates of suicide than men, the rate of suicide among females peaks between the ages of 45 and 64 at 9.7 deaths per 100,000 people.4
In many other countries around the world, elderly suicide rates are even higher. Worldwide, the senior citizen suicide rate (for those 70 and older) is about 27.5 deaths per 100,000 people. Yet, in some nations, the rate is even more staggering. So, around the globe, which country has the highest rate of elderly suicide? That would be South Korea, with about 86 deaths per 100,000 people.5
Here's another important stat: When it comes to completing suicide, elderly people die from their attempts at a much higher rate than young adults (25 percent vs. 0.5 percent).2
Keep in mind that none of these statistics include physician-assisted death (i.e., so-called "assisted suicide"). For elderly people and younger adults with painful or debilitating terminal illnesses, the decision to seek medical aid in dying is an altogether different situation than contemplating suicide when comparatively healthy.
That's why it's essential that we all do a better job of understanding and recognizing the risk factors and warning signs that can affect or be displayed by a troubled senior. Suicide is not an inevitable consequence of mental health problems. Often, it can be prevented.
Why Suicide in the Elderly Happens
Despite progress in many other areas, our modern society still has shortcomings when it comes to how we think about aging, mental illness, and death. For example, many people stigmatize depression and mistakenly believe that suffering is always part of the aging process, which can make older adults reluctant to seek the right kind of help.
In fact, when it comes to suicide, senior citizens who've taken their own lives were much less likely to have visited a mental health professional in the month before their death than to have seen a primary care physician.3
Some people also have romanticized notions about suicide, which may be holdovers from the past. For instance, in ancient Rome, suicide was often seen as a way to die with honor—as long as you didn't have any mental problems. A traditional Roman suicide ritual may have involved appeasing the gods for shameful actions and being surrounded by your loved ones, ensuring that one of them heard your final words.6
Today, the reasons for late-life suicide are as diverse as the individual seniors who attempt it. But the risk of suicide is cumulative, meaning that multiple factors are usually involved. Each new risk factor affecting a senior increases the probability that he or she will attempt suicide.2 Adding to the overall risk is this fact: Baby boomers have committed suicide at higher rates than those in other generations, which may continue into their senior years.7
Among older adults, suicidal behavior is mainly associated with:7
Seniors who've lost a close family member within the previous six months have the highest risk of suicide.3 Other factors that can increase an older adult's risk of suicide include:
- Alcohol abuse
- Chronic pain
- Cognitive impairment
- Elder abuse
- Employment changes
- Family conflict
- Fear of being a burden on others
- Lack of access to mental health care
- Loss of independence
- Loss of friends or pets
- Being male
- Money problems
- Physical disability
- Trouble adapting to change
Warning Signs of Potential Elder Suicide
When it comes to the potential for suicide in older adults, the danger signs can sometimes be easy to miss. After all, many seniors have fewer social interactions than younger people, and they may have extra determination to take their own lives. They may even work harder at hiding their intentions so as not to ruin their plans. Plus, seniors who live independently or semi-independently often have more ability to keep their suicidal thoughts and preparations to themselves.
Even so, it is possible to assess the risk of suicide. In elderly people, the potential for suicide can reveal itself in many different ways. Some of the things to watch out for include:
Seniors who have previously attempted suicide may also be at higher risk of making future attempts.
Elderly Suicide Prevention
If you suspect that a senior is seriously thinking about taking his or her own life, it's essential to respond to the issue as quickly as possible. Preventing suicide in the elderly often requires action on multiple fronts. According to the Mayo Clinic, intervening is always the most appropriate option—even if you have doubts about what to do. You're unlikely to make things worse; on the contrary, you may help reduce the person's suicidal impulses.8
Get immediate help if you believe that a suicide attempt is imminent. Otherwise, here are some actions you may be able to take:
Getting Immediate Help
First, take a slow, deep breath and tell yourself that you can get through this—no matter how upsetting the situation may be.
If the person intends to commit suicide but hasn't yet made an attempt:
- Encourage the senior to call the Friendship Line at 1-800-971-0016.
- Call 911 on a separate phone, if possible.
- Stay close by. Do not leave him or her alone until help arrives.
If the person has already attempted suicide:
- Call 911 and stay with the senior, following the instructions you're given.
- Alternatively, drive the senior to the emergency department of a nearby hospital (but only if you can do so safely).
- Take notice of any medications, alcohol, or other substances the senior may have used.
In the event that someone you care about doesn't survive a suicide attempt, seek grief counseling as soon as possible. Also, you may benefit from attending a local support group for survivors of suicide loss.
If YOU have the impulse to attempt suicide:
- Go to a place where other people are nearby. Do not isolate yourself.
- Call your counselor or therapist if you have one.
- Alternatively, call the Friendship Line at 1-800-971-0016.
Death With Dignity Facts and Laws
Death with dignity (i.e., physician-assisted dying) takes place in a completely different context than suicide. It empowers eligible terminally ill adults to plan peaceful deaths at the times and locations they choose.
In the U.S., Oregon's Death with Dignity Act was the first law of its kind. It came into effect in 1997. Washington state followed with its own law roughly a decade later.
As of September 2019, death with dignity is legal in nine American states as well as the District of Columbia (DC). California, Colorado, Hawaii, Maine, New Jersey, Oregon, Vermont, and Washington have assisted-dying laws that make physician-assisted death legal. Medical aid in dying is also legal in Montana by virtue of a 2009 ruling by the state's Supreme Court.9
In addition, death with dignity is legal in Canada, where it's known as medical assistance in dying (MAID). It is also legal in Columbia, the state of Victoria in Australia, and a few European countries, including Belgium, the Netherlands, and Luxembourg. In Switzerland, the practice isn't explicitly authorized by law, but it also isn't forbidden as long as it is carried out for so-called "non-selfish" reasons.10
In the places where it is legal in the United States, the requirements for death with dignity are generally that you must be:13
- At least 18 years old
- A resident of a state (or DC) that has a death with dignity law
- Terminally ill with a medical prognosis of six months or less to live
- Mentally capable of making and communicating your own medical decisions
- Physically capable of self-administering and ingesting the lethal medication prescribed for you
In terms of the residency requirements, you simply need to prove that you currently live in the region where you intend to die with physician assistance. It isn't necessary to show that you've been a resident for any minimum length of time. But you do need to provide documentation of your current residence.
For example, if you want physician-assisted death in Oregon, your proof of residency could be an Oregon driver's license or ID card, a copy of your recent state tax return, proof of voter registration in the state, or papers that show that you currently own or rent a home in the state. But to qualify for death with dignity, you do not have to live in Oregon for any specific amount of time.
California, Colorado, Hawaii, and Washington have the same residency requirements as Oregon. In the other regions where death with dignity is legal, the documentation requirements are similar but a little more varied.
In addition to the above requirements, you must follow all of the required steps in the process, which include getting approval from two physicians and adhering to two waiting periods.
In Canada, the law is more flexible. For example, it allows for voluntary euthanasia, meaning that a doctor or nurse practitioner can administer the lethal medication if you prefer not to self-administer it. Also, you do not have to be terminally ill for euthanasia or medical assistance in dying in Canada, but you do have to meet certain requirements, including:11
- Being at least 18 years old
- Qualifying for publicly funded health care in Canada
- Having a serious illness or disability that has progressed to a state of irreversible functional deterioration, causes intolerable physical and mental suffering, and makes your natural death "reasonably foreseeable"
- Making a voluntary, uncoerced request for medical assistance in dying
- Providing informed consent after being told that other options like palliative care are available to help ease your suffering
- Having the ability to provide informed consent at the moment when medical assistance in dying is to be carried out
Some Canadian courts have ruled that the "reasonably foreseeable" clause is invalid if interpreted to mean that someone has to be at or near the end of life. So going forward, that clause may not be an obstacle to eligibility for certain patients who are experiencing intolerable suffering but are not expected to die from their conditions in the near future.
Simply put, a wide variety of suffering patients qualify for voluntary euthanasia in Canada if they don't want (or are physically unable) to self-administer lethal medications. But they must be evaluated by at least two independent health care practitioners in order to qualify for medical assistance in dying. Canadian law also has other requirements that must be followed, such as a waiting period and independent witnesses to your request.
Under state laws for death with dignity, it is incorrect to label the practice as physician-assisted "suicide." Statistics, moreover, show no indication of these laws being widely abused.12 In fact, you may be surprised to learn that:
As previously mentioned, among other places, death with dignity is legal in California, Colorado, Oregon, Vermont, and Washington. Across those five states, almost 549 people die each year, on average, as a result of self-administering lethal medications that were legally prescribed for them under laws for physician-assisted dying. But those patients only represent about 66 percent of people who receive such prescriptions.14 (Many people request death with dignity but ultimately choose not to go through with it.)
Why Death With Dignity Is Different Than Archaic Cultural Customs
It's important to distinguish today's medical aid in dying laws from past cultural customs and practices that many people associate with elderly euthanasia. History, after all, includes unsettling stories from various cultures around the world about the killing of old people.
Also known as senicide or geronticide, the practice of killing elderly people through abandonment or other means (sometimes at their request) has shown up in many historical narratives. Although reliable information about such practices is relatively sparse, some cultures from the past have been said to engage in traditions like:15
- Leaving elderly people alone on the top of mountains
- Sacrificing and eating old men
- Ritualistically killing older adults with certain weapons
- Having children slay their elderly parents with swords
- Throwing elderly people to dogs that have been trained to kill them
Most of us who are alive today would probably view such practices as grisly and barbaric. But those customs didn't always constitute murder; sometimes they were a form of voluntary euthanasia. Elderly people, in certain cultures, wished to die in accordance with traditions that would be outrageous and illegal by today's standards.
One of the most widely circulated stories concerns the Inuit (often referred to by terms that many people find derogatory, such as "Eskimo"). Elderly Inuit people are said to have been put on ice floes and left to die from freezing and starvation—a rare, abandoned practice that some Inuit people and anthropologists have verified but that some scholars have disputed. For those who believe the practice took place, it's thought that some Inuit elders viewed that form of death as an appropriate way to end a life that had become "too much." Other Inuit death rituals involved placing a deceased person's body within a ring of rocks so that the wind wouldn't blow away his or her disintegrating bones.15
Today, when debating whether to make physician-assisted death or voluntary euthanasia legal, some opponents of the idea like to equate it with archaic cultural customs (such as those just mentioned). But proponents of dying with dignity believe that such characterizations are unfair and intellectually dishonest. They argue that death with dignity laws allow for humane, non-violent deaths—without cultural coercion—for those who will die soon anyway and don't wish to prolong their suffering (not for those who feel they've gotten "too old").
Arguments For and Against Death With Dignity
Although it's legal in multiple states, physician-assisted dying remains highly controversial. Still, most Americans support the idea of allowing physicians to help terminally ill patients end their lives. In fact, when the phrase "commit suicide" isn't part of survey questions about this issue, more than 70 percent of Americans express support for death with dignity. Even when that phrase is included, about 65 percent of Americans still support the concept.1
Death with dignity is a particularly divisive issue among physicians. The American Medical Association is against the practice; however, many other medical associations in the U.S. and elsewhere have endorsed the idea. A lot of physicians believe that medical aid in dying goes against the Hippocratic Oath, which, in some modern variations, says:16
If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
Yet, opinions vary as to whether the oath is adequate or even still relevant. That's partly why, according to one poll, about 56 percent of physicians have a positive opinion of death with dignity laws. And among physicians in states that don't have such laws, more than 60 percent say that they've had cases in which they would have liked their patients to have the option of physician-assisted death.17
But the many arguments for and against making death with dignity legal can be incredibly varied.
Arguments in Support of Physician-Assisted Dying
Arguments Against Physician-Assisted Death
Dying With Dignity: The Typical Process
Before going down this path, it's important for terminally ill seniors to carefully consider all available options for their end-of-life care. This is especially critical if you have a progressive illness that might make you unable to provide informed consent, make decisions, or ingest the lethal medication prescribed for you when the time comes to do so. Under state death with dignity laws, you must be mentally competent and physically capable of ingesting the necessary medications at the time of your planned death.
So make sure you explore your options for palliative and/or hospice care. Besides, even if you choose physician-assisted dying, you can still benefit greatly from such care in the weeks or months leading up to your death—especially if your illness causes pain or other distressing symptoms. On average, palliative care costs about $95 per day.20 But that cost is frequently covered by Medicaid, Medicare, or private insurance.
In the states where death with dignity is legal, the entire process often takes at least a few weeks. Here's what you typically need to do:
1. Speak with your physician, make your first verbal request, and get authorization.
A good time to bring up death with dignity is when you and your doctor are talking face-to-face about other end-of-life options like palliative and hospice care. Just remember that a lot of physicians aren't receptive to this idea, at least initially. You'll need to share your reasons for wanting physician-assisted death, making it clear that you understand your prognosis, have been considering the alternatives, and don't wish to suffer needlessly.
Verbally ask your physician whether he or she would be willing to support your decision to die with dignity by writing you a prescription for lethal medication in accordance with the applicable state law. Request a simple answer: yes or no. If your physician says no, accept his or her decision. But make sure that your request gets documented as part of your medical record.
It's possible that your doctor will not be willing to prescribe the lethal medication for you but would still be willing to act as a consulting physician—confirming your mental competence, diagnosis, and prognosis. Regardless, you will need the participation of two physicians. Both will need to evaluate your medical condition and mental judgment. But only one (the attending physician) will need to be willing to prescribe lethal medication.
Since you need two participating doctors, ask for a referral to another physician, no matter how he or she answers. And keep in mind that any type of licensed physician can participate, regardless of specialty.
You won't be able to proceed until you receive physician authorization.
2. Tell your friends and family.
Although it isn't legally required, talking to your loved ones about your plans for a physician-assisted death is highly recommended. After all, they'll need time to digest the information and process their feelings, regardless of whether they support the idea. In the best-case scenario, your loved ones will come to understand your decision, stand by you, and provide aid in planning the peaceful death that you want and deserve.
3. Comply with the first waiting period.
After receiving physician authorization, you typically need to wait at least 15 to 20 days before proceeding to the next step. The exact waiting period depends on your state's death with dignity law.
4. Make your second verbal request.
Speak to your attending physician, again requesting assistance to die with dignity in accordance with the relevant law in your state.
5. Submit a request in writing.
Each state with a physician-assisted dying law has its own forms to use for this purpose. So the requirements vary a little, depending on where you're going through this process. Generally, you must wait to submit your written request until any time after you've made your first verbal request. However, in the District of Columbia, you must also make this written request before your second verbal request. In addition, you may need to have your signature witnessed by two people who meet specific requirements.
6. Observe the second waiting period.
This doesn't apply in Colorado or California. For other regions where death with dignity is legal, your attending physician can only write the prescription for your lethal medication after waiting at least two full days from the time of receiving your written request.
7. Pick up your prescribed medication.
Under state laws for death with dignity, medication prescriptions must be delivered directly by your attending physician to a pharmacy. Once your pharmacy has the prescription, you can choose when to have it filled. And you can designate someone else to pick up the medication when it is ready. But remember: You do not have to fill the prescription if you end up having a change of heart.
Physicians aren't required to prescribe any specific medications. So prescriptions can vary from patient to patient and region to region. And the preferred medications for physician-assisted dying have changed over the years. Today, a commonly recommended combination of diazepam, morphine, digoxin, and amitriptyline is given for death with dignity in the U.S.21 (Another common protocol uses propranolol instead of amitriptyline.22)
Using that four-drug cocktail means that it costs roughly $700 to $750 to die with dignity, unless you can afford and access the medications commonly used in Europe.21 For example, Seconal is frequently unavailable in the U.S., and even if you can access it, it tends to cost between $3,000 and $5,000. Pentobarbital is also notoriously hard to access in America because the European Union has banned its export.13 Both of those medications are known to be fast-acting and provide for painless deaths.
That's why a non-profit organization in Switzerland called Dignitas often uses pentobarbital to kill patients who seek their help in dying with dignity. But it can cost thousands of dollars for assisted dying if you're an American who wants to die overseas by using that medication. (Most of your expenses would be travel-related.)
By staying back in the U.S., you'll be able to die with dignity at home, a lot more affordably. At this point in the process, you just have to decide when the time is right to commence your final act.
8. Plan a time and location, then ingest your medication.
Remember that in order to retain your legal protections, you can only take the lethal medication in the state where you received it. Otherwise, you are free to choose when and where you wish to die—if you still want to. (A significant number of patients ultimately choose not to end their lives this way. You're under no obligation to ingest the medication, even if you've come this far in the process.)
Many patients choose to be surrounded by close family and friends during their final moments. Others prefer to have privacy for this part of their journey. Whatever you decide is OK. Either way, you will need to administer the medication yourself. You can, however, have someone help you prepare it.
You may need to ingest multiple medications in a particular sequence, including meds to prevent nausea, to put you to sleep (and keep you asleep), and to ensure that you don't feel pain. You will likely fall into a peaceful sleep within 10 or 15 minutes. Then, it will take a little longer to pass away. For most patients, it takes about three hours or less to die with dignity in this way. However, for a small percentage of patients, it can take at least double that amount of time.23
Regardless of how long it takes for you to pass away, the medications should keep you in a comfortable state of painless, unconscious sleep until your peaceful end finally comes.
Embrace Knowledge and Compassion
Elderly suicide and death with dignity may be separate issues, but it's important to understand the facts surrounding both. That way, you can be better prepared to support a troubled or ailing senior in your life—as well as yourself.
- 1 Gallup, "Americans' Strong Support for Euthanasia Persists," website last visited on September 19, 2019.
- 2 Psychiatric Clinics of North America, "Suicide in Older Adults," website last visited on September 19, 2019.
- 3 Clinical Interventions in Aging, "Suicide in older adults: current perspectives," website last visited on September 19, 2019.
- 4 Centers for Disease Control and Prevention, "Suicide Mortality in the United States, 1999–2017," website last visited on September 19, 2019.
- 5 Our World in Data, "Suicide," website last visited on September 19, 2019.
- 6 Kennedy, Angela Dawne, "Blood Sacrifice: The Connection Between Roman Death Rituals and Christian Martyrdom," Honors Theses, website last visited on September 19, 2019.
- 7 Kaiser Health News, "Lethal Plans: When Seniors Turn to Suicide In Long-Term Care," website last visited on September 19, 2019.
- 8 Mayo Clinic, "Suicide: What to do when someone is suicidal," website last visited on September 19, 2019.
- 9 Death with Dignity National Center, "Death with Dignity Acts," website last visited on September 19, 2019.
- 10 The Conversation, "From Oregon to Belgium to Victoria – the different ways suffering patients are allowed to die," website last visited on September 19, 2019.
- 11 Dying With Dignity Canada, "Get the Facts: Bill C-14 And Assisted Dying Law in Canada," website last visited on September 19, 2019.
- 12 JAMA: The Journal of the American Medical Association, "Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe," website last visited on September 19, 2019.
- 13 Death with Dignity National Center, "Frequently Asked Questions," website last visited on September 19, 2019.
- 14 ProCon.org, "State-by-State Physician-Assisted Suicide Statistics," website last visited on September 19, 2019.
- 15 Nowhere, "Death and Dying in the Canadian Arctic: On Senicide, Rogue Polar Bears, and Life in Cape Dorset," website last visited on September 19, 2019.
- 16 NOVA, "The Hippocratic Oath Today," website last visited on September 19, 2019.
- 17 Medscape, "Doctor Support for Assisted Death Rises, but Debate Continues," website last visited on September 19, 2019.
- 18 Animal Sentience, "Can nonhuman animals commit suicide?," website last visited on September 19, 2019.
- 19 Death Penalty Information Center, "Lethal Injection and Physicians: State Law vs. Medical Ethics," website last visited on September 19, 2019.
- 20 The Pew Charitable Trusts, "Why Some Patients Aren't Getting Palliative Care," website last visited on September 19, 2019.
- 21 MarketWatch, "How 'death with dignity' laws allow terminally ill patients to take back control—sometimes at a price," website last visited on September 19, 2019.
- 22 The Atlantic, "The Doctors Who Invented a New Way to Help People Die," website last visited on September 19, 2019.
- 23 Death with Dignity National Center, "How Death with Dignity Laws Work," website last visited on September 19, 2019.