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On October 5, 2015, Governor Jerry Brown approved bill ABX2 15, the End of Life Option Act, making California the fifth state in the country to allow physician-assisted dying. The law was modeled after Oregon's 1997 Death with Dignity Act. When the legislative special session ended on March 10, 2016, California health care providers had only ninety days to respond to the state mandate before the law would take effect, on June 9, 2016. Experience with the law so far suggests several challenges with implementation.

When the Supreme Court of Canada recognized a constitutional right to “medical assistance in dying” last year—and the nation's Parliament enacted legislation to implement the right earlier this year—Canadian lawmakers could look to two different models for guidance. The Netherlands and Belgium recognize a broad right to assistance in dying, while Oregon and elsewhere in the United States have a narrow right. In some ways, assistance in dying in Canada follows the Dutch-Belgian approach, while, in other ways, it seems more American. Two societal factors seem relevant to the different approaches: the role that religion plays in people's lives and the trust that people place in their governments and health care systems. As other governments consider legalizing assistance in dying, an important question is whether some restrictions on the right are particularly critical. The experience to date suggests that requiring patients to be terminally ill has provided the best protection against misuse.

A commentary on “Physician Assisted Dying: A Subtler Slippery Slope,” by Thomas Duffy, in the March-April 2014 issue.

I served as a medical student and resident in the 1960s. Science as a belief system had reached a pinnacle. Yet Not infrequently in those days, I found myself caring, with little available backup, for a hospital ward filled with sick and dying people. It was a lonely and often frightening responsibility. I began to encounter situations that were at odds with our collective certainty that science would provide the answers. Some of these memories I repressed for almost a decade. I was unable to process them until I had personally experienced a more humanistic side of medicine.

Although physician-assisted death can be a great benefit both to those who are terminally ill and those who are not, the risks for patients in these two categories are quite different. For now it is reasonable to make the benefit available only for those near death, and to await better evidence about the risks before making it more broadly available. (HCR)

Early this spring, I met a musician, the composer Pauline Oliveros, a beautiful woman like a grey rock in a streambed; and to a group of us, women, who were beginning to quarrel over theories in abstract, objective language--and I with my splendid Eastern-women's-college training in the father tongue was in the thick of the fight and going for the kill--to us, Pauline, who is sparing with words, said . . . "Offer your experience as your truth." There was a short silence. When we started talking again, we didn't talk objectively, and we didn't fight. We went back to feeling our way into ideas, using the whole intellect not half of it, talking with one another, which involves listening. We tried to offer our experience to one another. Not claiming something:,offering something. (Ursula LeGuin)[1] This essay concerns the role of appeals to experience in moral deliberation. In what follows, I want to explore what it would mean to take LeGuin's advice seriously when writing about moral issues. In calling for attention to personal experience--particularly the experiences of women--LeGuin is adding her voice to those writers who have called for the integration of reason and emotion, the personal and the political, the public and the private. In moral theory, the attempt to overcome such dichotomies has been part of a general effort to reverse the segregation of intellectual inquiry from personal experience in moral deliberation. Indeed, a common theme in many of the works that might be collected under the rubric of "feminist ethics" is the centrality of personal experience. Yet how, precisely, should appeals to experience function in moral argument? Should personal experience be a privileged source for moral reflection? What authority does experience have in moral argument? How do we adjudicate conflicting appeals to experience? Although I cannot possibly answer adequately all of these questions in so brief a space, they will help frame my discussion. We can begin by noting that the use of experience in moral deliberation is rarely critically examined and that the appeal to experience is often treated almost as a panacea. So if we are to understand how appeals to experience may serve an important function in moral deliberation, we must begin critically. Only then can we turn to a more constructive account of the role appeals to experience play in moral deliberation. Some Problems with the Appeal to Experience We can get a sense of some of the problems here by looking more closely at LeGuin's own uncritical celebration of appeals to experience. To be sure, there is much to affirm in this passage. Anyone familiar with academic conferences knows the sort of intellectual violence implied by LeGuin's comment about "going for the kill," and also how unproductive such academic fighting usually is. So I agree with LeGuin that offering your experience as your truth is frequently more productive than fighting in abstract "objective" language. Yet why suppose that offering your experience would put an end to argument? Why suppose that, if we only shared our experiences with each other, divisiveness would disappear? To be fair, LeGuin does draw a distinction between "offering" and "claiming" and this distinction is important if we are to insist that the appeal to experience is the beginning rather than the end of moral deliberation. LeGuin is right: to offer your experience as your truth is not to claim that you have the Truth with a capital T It is a starting point, an invitation to conversation. However, once we acknowledge that the appeal to experience is not the end but the beginning of moral deliberation, we are in a position to see why such appeals are unlikely to have the sort of palliative effect on moral disagreement that LeGuin claims for them. An appeal to experience could only put a stop to argumentation if we misconstrue it as a move of last resort. Thus, LeGuin's remarks point to one significant danger here, namely, that experience will be treated as a sort of trump. …

Some subjects in ethics elicit a far greater degree of emotional discomfort than others. It is not the delicacy or complexity of the subject as such that seems to be the problem. It is, instead a tacit recognition that, try as we might, it is especially hard to disentangle our personal response from the issues themselves. And this makes it especially hard to avoid self-deception and self-interest in our analysis. Terminating life-sustaining treatment for demented patients is such an issue. Dementia is universally feared, more so than almost any other disease. Few of us can tolerate the thought that we might become its victim. Even if we can bring love and devotion to the care of those with dementia, they can in turn elicit in us the fear that we might someday be ourselves so afflicted, and they can incite a sense of loathing and horror, usually despite ourselves. We cannot easily distinguish our own feelings about the condition from what is the actual good of the patient. The harder it is for us to imagine life as tolerable in such circumstances, the harder it will be to determine what is beneficial for the patient. This same troubling dimension will, analogously, almost surely begin playing itself out in the years to come on the social and economic level, as a combination of increased numbers and likely higher costs for the care of those afflicted with dementia becomes a more explicit agenda item for resource allocation, Will society show the same kind of ambivalence, self-questioning, and anguish felt by many individuals as it further develops policies and spending patterns? If so, how will it incline in its values and predilections, with increased generosity or discreet withdrawal? The general question I want to pursue is this: under what circumstances should life-sustaining treatment for dementia patients be ended and the patients allowed to die? The more specific, troubling, question is: ought the fact of dementia make a difference in our decision, distinguishing it from other termination situations? These questions would have been much easier to deal with ten or fifteen Years ago. They are harder now for three reasons--reasons which, vexingly enough, move in different, conflicting directions. The first reason is that recent research on Alzheimer disease is beginning to show that much more can be done for its sufferers than was previously possible and that a viable, even if crippled, self may endure far later into the disease process than was earlier believed. The second reason is that new sensibilities about disabled populations have emerged over the past few decades that have alerted us to the possibility of stigmatizing and demeaning the demented, thus worsening their situation. The third reason is that, one way or another, health care resources will become more limited in the future, and the explicit, open rationing of health care more certain; dementia is not likely, nor should it be spared from scrutiny in that process. It would be ideal to develop a way of thinking about Alzheimer that managed to take on all three of these problems simultaneously despite their potential conflict, seeing if they can be dealt with in a way that is integrated and coherent. I will initially sketch a context to help situate the care of dementia patients and the termination of their treatment Then I will move on to develop some criteria to make termination decisions. A Context for Analysis The pertinent context here is threefold: (1) our knowledge of the inner life, and selfhood, of those suffering from dementia (by which I will primarily mean Alzheimer disease); (2) the messages, symbolic and literal, about dementia that could be conveyed to society by alternative kinds of policies and practices; and (3) the economic considerations involved in making decisions about the good of individual patients. Dementia and the Self. Two major problems need to be noted. One of them, to which I will not devote much attention, bears on the place and force of advance directives in the care of the demented. …

Advocates use case descriptions to show that euthanasia or assisted suicide is sometimes justifiable. Yet even the seemingly clearest cases can prove deeply troubling.

Is suicide, as Aristotle held in the Nicomachean Ethics, an act of injustice against the city-state (unless actually required by that state, as in the case of Socrates)? Should community interest outweigh those of individuals both in barring most people from taking their own lives and in requiring some to do just that? Or should individuals be free to choose death regardless of community interests, as Seneca urged? Having been Emperor Nero's tutor, Seneca knew well the potential for state injustice both in taking human life and in prolonged torture of the living. In a letter to his friend Lucilius, he insisted that "a man is bound to justify his life to others, his death only to himself." To this day, the tension persists between the concerns of the community and individuals when it comes to suicide, assisted suicide, and euthanasia. Even as technology has brought new means both of ending and of prolonging life, debates about the legitimacy of choosing death still center around issues of justice: of what is owed to the community, to families, and to individuals facing suffering such that they envisage death as a release. Twenty-five years ago, I focused on these issues in completing my doctoral dissertation on voluntary euthanasia. In contrast to the atrocities of the Nazi "euthanasia program," advocates of legalizing euthanasia stressed its voluntary aspect. Mercy killing, they aruged, should only be permitted if requested in the presence of witnesses by fully competent individuals who were terminally ill, suffering greatly, and near death. I found the conflict both sharp and poignant, between, on the one hand, the legitimate desires of individuals for release from great and irremediable suffering; and, on the other hand, the societal imperative to guard against the risk of abuses and errors and pressures to expand the practice of euthanasia, once the present strong prohibitions against killing, inadequate as they too often are, are further relaxed. The legitimate concern of individuals to refuse treatment and even to speed their own deaths ought to be respected, I concluded. But the societal imperative rendered legalizing voluntary euthanasia unacceptable. To be sure, the risks of error and abuse would be lower in a world in which laws were more consistently honored, families closer and less burdened by financial pressures, and the judgment of physicians more uniformly trustworthy. But if euthanasia were made lawful in existing societies, it might come to be inflicted upon individuals either unable or unwilling to request it--especially upon those thought too weak, too incompetent, or too expensive to maintain in life. In writing on this question twenty-five years ago, I did not know about the birth of The Hastings Center and thus could not foresee how greatly it would contribute to the public debate and the scholarly analysis of issues having to do with death and dying. …

The due process clause of the Fourteenth Amendment protects the right of terminally ill persons to hasten their inevitable death. In prohibiting physicians from prescribing lethal medications by which such patients might hasten death, Michigan's ban on "assisted suicide" unconstitutionally imposes an "undue burden" on the exercise of that right.

To gain a better way of thinking about medical technology and our human mortality, we should begin backward. Death should be seen as the necessary and inevitable end point of medical care.... We as a society remain uncertain about the status of patients who manage to combine, in a bewildering way, elements of both life and death.

To speak of rights in the very troubling matter of medically managed death is ill suited both to sound personal decisionmaking and to sensible public policy. There is no firm philosophical or legal argument for a "right to die."

The euthanasia debate is not just another moral debate, one in a long list of arguments in our pluralistic society. It is profoundly emblematic of three important turning points in Western thought. The first is that of the legitimate conditions under which one person can kill another. The acceptance of voluntary active euthanasia would morally sanction what can only be called "consenting adult killing." By that term I mean the killing of one person by another in the name of their mutual right to be killer if they freely agree to play those roles. This turn flies in the face of a long-standing effort to limit the circumstances under which one person can take the life of another, from efforts to control the free flow of guns and arms, to abolish capital punishment, and to more tightly control warfare. Euthanasia would add a whole new category of killing to a society that already has too many excuses to indulge itself in that way. The second turning point lies in the meaning and limits of self-determination. The acceptance of euthanasia would sanction a view of autonomy holding that individuals may, in the name of their own private, idiosyncratic view of the good life, call upon others, including such institutions as medicine, to help them pursue that life, even at the risk of harm to the common good. This works against the idea that the meaning and scope of our own right to lead our own lives must be conditioned by, and be compatible with, the good of the community which is more than an aggregate of self-directing individuals. The third turning point is to be found in the claim being made upon medicine: it should be prepared to make its skills available to individuals to help them achieve their private vision of the good life. This puts medicine in the business of promoting the individualistic pursuit of general human happiness and well-being. It would overturn the traditional belief that medicine should limit its domain to promoting and preserving human health, redirecting it instead to the relief of that suffering which stems from life itself, not merely from a sick body. I believe that, at each of these three turning points, proponents of euthanasia push us in the wrong direction. Arguments in favor of euthanasia fall into four general categories, which I will take up in turn: (1) the moral claim of individual self-determination and well-being; (2) the moral irrelevance of the difference between killing and allowing to die; (3) the supposed paucity of evidence to show likely harmful consequences of legalized euthanasia; and (4) the compatibility of euthanasia and medical practice. Self-Determination Central to most arguments for euthanasia is the principle of self-determination. People are presumed to have an interest in deciding for themselves, according to their own beliefs about what makes life good, how they will conduct their lives. That is an important value, but the question in the euthanasia context is, What does it mean and how far should it extend? If it were a question of suicide, where a person takes her own life without assistance from another, that principle might be pertinent, at least for debate. But euthanasia is not that limited a matter. The self-determination in that case can only be effected by the moral and physical assistance of another. Euthanasia is thus no longer a matter only of self-determination, but of a mutual, social decision between two people, the one to be killed and the other to do the killing. How are we to make the moral move from my right of self-determination to some doctor's right to kill me - from my right to his right? Where does the doctor's moral warrant to kill come from? Ought doctors to be able to kill anyone they want as long as permission is given by competent persons? Is our right to life just like a piece of property, to be given away or alienated if the price (happiness, relief of suffering) is right? And then to be destroyed with our permission once alienated? …

In its September/October 1990 issue, the Hastings Center Report published six brief essays with a short introduction by Courtney S. Campbell under the collective title of "Cruzan: clear and convincing?" These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (June 25, 1990). Legal scholar Charles Baron, though an advocate for patients' rights in general and the right to die in particular, argues that the Supreme Court rendered the right decision in Cruzan.

In its September/October 1990 issue, the Hastings Center Report published six brief essays, with a short introduction by Courtney S. Campbell, under the collective title of "Cruzan: clear and convincing?" The individual authors and titles are: William H. Colby, "Missouri stands alone"; Pete Busalacchi, "How can they?"; Charles Baron, "On taking substituted judgment seriously"; John A. Robertson, "Cruzan: no rights violated"; Ronald E. Cranford, "A hostage to technology"; and Joanne Lynn and Jacqueline Glover, "Cruzan and caring for others." These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (June 25, 1990). William H. Colby is the attorney who represented the Cruzan family throughout its legal battle to have Nancy's feeding tube removed.

The "Ethics committees" column in this issue of the Hastings Center Report features an introduction by Cynthia B. Cohen and four brief commentaries on the roles hospital ethics committees may play in the making of institutional and public health care policy in the 1990s. The implications for ethics committees of the pending federal Patient Self-Determination Act are discussed here by John C. Fletcher in "The Patient Self-Determination Act: yes," and by Alexander Morgan Capron in "The Patient Self-Determination Act: not now." Fletcher is director of the Center for Biomedical Ethics at the University of Virginia. He presents two case studies involving decisions on life-sustaining treatment.

In its September/October 1990 issue, the Hastings Center Report published six brief essays with a short introduction by Courtney S. Campbell under the collective title of "Cruzan: clear and convincing?" These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Department of Health. Joanne Lynn, a physician, and Jacqueline Glover, a clinical ethicist, discuss possible responses from health care professionals to foster compassionate decision making policies in the wake of the June 25, 1990 Cruzan decision.

In its September/October 1990 issue, the Hastings Center Report published six brief essays with a short introduction by Courtney S. Campbell under the collective title of "Cruzan: clear and convincing?" These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (June 25, 1990). Legal scholar John A. Robertson argues that Cruzan was rightly decided, not because persons like Nancy Cruzan in a persistent vegetative state should be sustained indefinitely, but because sustaining them does not violate any party's constitutional rights.

Annas criticizes the U.S. Supreme Court's opinion in Cruzan v. Director, Missouri Department of Health, the first right-to-die case decided by the Court. In Cruzan, the Court held that the state of Missouri is not required to recognize the family's role in refusing artificial nutrition on behalf of a woman in a persistent vegetative state. In view of the state's legitimate interest in the protection and preservation of human life, the Supreme Court held that Missouri could require clear and convincing evidence that Cruzan expressed the wish, when competent, to have life-sustaining treatment withheld. Annas briefly reviews the Missouri Supreme Court decision in Cruzan, the "bloodless" majority opinion of the U.S. Supreme Court, and the "constitutionally correct and humanely compassionate" dissenting opinion written by Justice Brennan. He argues that the Constitution is becoming irrelevant in protecting citizens like the Cruzans from the power of the state and of technology.

In its September/October 1990 issue, the Hastings Center Report published six brief essays with a short introduction by Courtney S. Campbell under the collective title of "Cruzan: clear and convincing?" These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Deparment of Health (June 25, 1990). Pete Busalacchi is the father of a young woman, who, like Nancy Cruzan, is in a persistent vegetative state and a patient at the Missouri Rehabilitation Center. He voices his distress at seeing his daughter maintained in this condition.

In its September/October issue, the Hastings Center Report published six brief essays with a short introduction by Courtney S. Campbell under the collective title of "Cruzan: clear and convincing?" These articles present a range of responses from participants, parents, constitutional scholars, and caregivers to the U.S. Supreme Court's decision in Cruzan v. Director, Missouri Department of Health (June 25, 1990). Ronald E. Cranford is a neurologist and a consultant to the Cruzan family.

This is the first of a set of three articles concerned with "bioethics on the Pacific Rim." The author, vice president of Beijing Medical University and vice chairman of the Beijing Academic Association for Morality, identifies population control, euthanasia, and the allocation of health care resources as bioethical issues of current interest in his country. Population policy in China is grounded in public welfare arguments. The idea of a right to choose one's death is found in Chinese philosophy, although Chinese legal experts believe that euthanasia is not compatible with present criminal, civil, or family law. Allocation of health resources remains a problem in China, even throughout the free medical service that serves a small portion, largely composed of government employees, of the country's population of 1.08 billion.The systematic study of modern medical ethics and bioethics in China began in the early 80s, although medical moral theory dates back to 475 B.C. In October l988 the 1st Chinese bioethics association was founded. The most popular topics for their symposia include: population control, euthanasia, and the allocation of health care resources. Birth control and population policy in China are both attempting to slow the 15 million annual increase in population. Family planning services are available for all married couples that seek it including sterilization and abortion. The current policy is that families should have only 1 child; ethnic minorities and rural residents are exempt. All policies on population control, abortion, and contraceptives are grounded in public welfare arguments. What they oppose is a long tradition in Chinese culture of large families. Euthanasia in China is an old topic with traditional wisdom stating that each person should have the right to chose their means of death. However for medical personnel it provides 2 dilemmas. 1st, the deontological position that doctors have a duty to both saving a patient's life and relieving pain. The doctor can not forsake one for the other. 2nd, the patient's personal benefits may conflict with the family's or society's overall benefits. Legal experts in China feel that euthanasia is incompatible with Chinese marriage law which prohibits the mistreatment or abandonment of family members. Allocation of medical resources is another issue because 800 million Chinese are not covered under the state's free medical care. Of those who are, there is limited capacity and the issue of who gets care is currently being debated.