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Euthanasia and Physician-Assisted Suicide
A Review of the Empirical Data From the United States
Ezekiel J. Emanuel, MD, PhD
Arch Intern Med. 2002;162:142-152.
INTRODUCTION
For more than a decade, there has been an intense debate about the ethics
and legality of euthanasia and physician-assisted suicide (PAS) in the United
States.1-5
In June 1997, the US Supreme Court unanimously ruled that there is neither
a constitutional right nor a constitutional prohibition to euthanasia or PAS.6-7 This permitted Oregon to experiment
with legalizing PAS. During this decade, most other states have consistently
opposed legalization. In the weeks after the US Supreme Court decision, the
Florida Supreme Court also ruled that there is no constitutional right to
PAS.8 At least 7 state legislatures have voted
to explicitly prohibit euthanasia and PAS.9
Indeed, a bill to legalize euthanasia or PAS has been considered by a full
chamber of a state legislature in only one state, Maine, and that bill was
defeated 99 to 42.10 In November 1998, 70%
of the voters of Michigan resoundingly defeated a referendum to legalize PAS,
while in November 2000 Maine voters also rejected legalizing PAS.11
The extensive debates for and against euthanasia and PAS have made the
arguments more refined, subtle, and sophisticated. Yet the essential claims—arguments
based on patients' autonomy to control their own lives and beneficence in
relieving excruciating pain and suffering—have remained remarkably the
same since the late 19th-century debates about euthanasia.5, 12
However, the current debate has spawned significant and unprecedented empirical
research, illuminating many aspects of and claims about euthanasia and PAS.
This article reviews the empirical data about euthanasia and PAS in the United
States regarding: (1) the public's attitudes, (2) physicians' attitudes, (3)
physicians' practices and experiences, (4) nonphysician health care professionals'
attitudes and practices, and (5) patients' attitudes and experiences. It will
conclude with a summary of the most important question in need of additional
empirical inquiry.
In this article, whenever the term euthanasia
is used, voluntary active euthanasia is meant. Other
forms of euthanasia, nonvoluntary or involuntary, have not been extensively
advocated or studied.5
ATTITUDES OF THE AMERICAN PUBLIC
There have been innumerable surveys of the American public on euthanasia
and PAS.13-15
Most information derives from a few questions added to general surveys and
do not probe deeply; only a few surveys have been in-depth analyses. In general,
opponents and proponents of euthanasia or PAS endorse 4 conclusions from these
data.
First, depending on how questions are worded and the types of choices
offered, public support for euthanasia or PAS can vary widely, from about
34% to about 65% (Table 1).13-14 In other words, some Americans are
firm in their views of euthanasia and PAS, while others are more labile. The
best way to understand public opinion might be by the "Rule of Thirds." Roughly,
one third of Americans seem to support voluntary active euthanasia or PAS
no matter what the circumstances. For instance, 29.3% of Americans support
euthanasia or PAS for terminally ill patients who are not in pain but desire
these interventions because they view life as meaningless. Similarly, 36.2%
support euthanasia or PAS for terminally ill patients who give as their reason
not wanting to be a burden on their family.16
These are the approximate one third whose support for euthanasia or PAS is not
affected by the interventions, the patient's motivations, or the circumstances.
Conversely, another third or so of Americans oppose euthanasia or PAS no matter
what the circumstances. Almost all the surveys report the highest levels of
support for euthanasia or PAS to be about 65%.13-16
These data mean that roughly one third of Americans—the difference between
100% of the public and the 65% who support euthanasia for patients in pain—oppose
euthanasia or PAS even for terminally ill patients who are experiencing unremitting
pain, despite optimal management. The remaining third or so of Americans constitute
the volatile public. They support euthanasia or PAS in some circumstances,
usually involving extreme pain, but oppose it in other circumstances, such
as for reasons of indignity or because the patient does not want to be a burden
(Table 2).
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Table 1. Framing Effects: Variations in the Public's Attitudes Toward
Euthanasia and Physician-Assisted Suicide (PAS) Depending on the Questions
Asked*
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Table 2. Variations in the Public's Support for Euthanasia and Physician-Assisted
Suicide (PAS) by Scenario and Intervention*
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Consequently, support for euthanasia or PAS is not as extensive as the
reports that two thirds of Americans support these interventions make it appear.
Furthermore, for few of these people is legalizing euthanasia or PAS a leading
issue, the primary element that will determine their vote. In this sense,
unlike abortion, euthanasia and PAS do not appear to be litmus test issues.
Second, surveys that assess trends over time indicate that the significant
rise in support for euthanasia and PAS occurred in the mid 1970s, not the
1990s.14 Indeed, since the mid 1970s, support
for these interventions has been constant (Table 1). Interestingly, this is similar to the trends found in
the Netherlands.17 Consequently, the extensive
public debates during the last decade do not appear to have shifted public
opinion significantly.
Third, while medical ethicists, philosophers, lawyers, and others have
spent much time debating whether euthanasia is fundamentally different from
PAS and elucidating potential distinctions, the American public does not seem
to make much of the distinction. Polls show that Americans support euthanasia
at the same rate that they support PAS (Table 2).15 Conversely, the public
does distinguish withdrawing life support or providing pain medications, even
with the increased risk of respiratory depression and death from euthanasia
and PAS.14-15 Despite arguments
by some philosophers suggesting that there is no moral difference,18 more than 90% of the public deem withdrawing life
support as ethical, while at best 65% support euthanasia or PAS.15
Finally, certain sociodemographic characteristics consistently predict
support and opposition to euthanasia or PAS.13-15
Catholics and people who report themselves to be more religious are significantly
more opposed to euthanasia or PAS. Similarly, African Americans and older
individuals are significantly more opposed to euthanasia or PAS. Finally,
some, but not all, surveys suggest that women are significantly more opposed
to euthanasia or PAS. Interestingly, patients with terminal illnesses, such
as cancer and chronic obstructive pulmonary disease, have attitudes that are
almost identical to the public's.16 In other
words, having a serious, life-threatening illness itself does not seem to
alter attitudes toward the permissibility or opposition to euthanasia or PAS.
Similarly, being a caregiver for a terminally ill patient or a recently bereaved
caregiver does not seem to affect attitudes toward euthanasia or PAS.16
ATTITUDES OF US PHYSICIANS
During the last decade, US physicians have been extensively surveyed
about euthanasia and PAS.19-48
Many of the surveys, especially the early ones, are problematic in their methods.5 The surveyed cohorts are narrow or biased, and the
response rates are low. More important, questions are frequently worded poorly
and abstractly in a confusing, emotionally laden, or biased manner. For instance,
they often conflate terminating medical treatments with euthanasia or ask
whether euthanasia or PAS is never ethically justified. Furthermore, many
of the questions use multiple hypothetical propositions—requiring leaps
of imagination by respondents—that are known to make the data unreliable.
For instance, physicians are frequently asked, if euthanasia or PAS were legalized,
would there be some circumstances in which they would be willing to perform
euthanasia or PAS? In addition, there has been no consistency among the questions,
making it difficult to compare the data across different surveys. In recent
years, the surveys have addressed some of these problems, making the data
more reliable, although there still appears to be the problem that physicians
confound euthanasia with terminating life-sustaining treatments and euthanasia
with PAS.16, 43
Surveys of physicians' attitudes have evaluated 3 issues that have not
usually been clearly distinguished: (1) belief that euthanasia or PAS is ethically
justifiable, (2) support for legalization of either intervention, and (3)
willingness to perform either intervention (Table 3).19-48
The more reliable surveys find that most US physicians do not view euthanasia
or PAS as ethical. The major exceptions seem to ask abstractly whether these
interventions might be justifiable "in some circumstances" (Table 3). More typical are surveys that report that fewer than half
of physicians support euthanasia or PAS, or those in which respondents find
suicide rational in some cases but believe that physicians should not assist
(Table 3).
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Table 3. Attitudes Toward Euthanasia and Physician-Assisted Suicide
(PAS) Among American Physiciansa
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Regarding legalization, among physicians there seems to be no consistent
pattern, probably because questions ask about specific legislation that varies
and because respondents may not be familiar with the particular facets of
the legislation. For instance, in a survey of Michigan physicians, Bachman
et al32 could demonstrate most physicians (56.6%)
supporting PAS only when they were forced to choose either legalization or
an explicit ban; without being forced into this choice, only 38.9% supported
permitting PAS. Consistently, few physicians would be willing to perform euthanasia
or PAS if either were legalized (Table 3).
These data demonstrate another important factor: unlike the American
public, US physicians distinguish between euthanasia and PAS. They are much
more likely to support providing PAS than euthanasia.15, 20, 25, 29, 37, 47-48
Only a few studies19, 35, 37, 42
have found most physicians supporting euthanasia. Therefore, unlike the American
public, support for euthanasia or PAS among US physicians crucially depends
on the intervention being asked about.15 This
is different from Dutch physicians, who do not seem to distinguish euthanasia
and PAS.47
There are important factors associated with support for euthanasia or
PAS. Like the American public, US physicians who are Catholic or religious
are significantly less likely to support euthanasia or
PAS.15, 21, 25, 29, 32-33,38, 42-43,47-48
Similarly, surveys have reported certain specialties as more supportive of
euthanasia or PAS than others.29, 31, 33, 43, 48
Surgical oncologists are more likely to support euthanasia or PAS than medical
oncologists. Psychiatrists and obstetricians and gynecologists are more supportive
of euthanasia or PAS, with internists, especially oncologists, less supportive.
Still, others have found family or general practitioners as more supportive
than internists.
Finally, at least among US oncologists, there appears to be a significant
decline in support for euthanasia or PAS between the early and late 1990s.15, 44, 48 Between 1994 and
1998, support for euthanasia and PAS significantly declined among oncologists
in the scenario of a patient terminally ill with cancer who had unremitting
pain.15, 48 Although it is hard
to know precisely why this decline has occurred, 2 explanations seem reasonable.
The recent focus on end-of-life care has revealed the multiplicity of interventions,
besides euthanasia and PAS, that can be used to improve the quality of life
of the terminally ill. Consequently, euthanasia and PAS seem less necessary
and desirable to ensure good end-of-life care. Furthermore, support tends
to be higher when considering euthanasia and PAS in the abstract, as a philosophical
question. But as they become more real and personal and physicians may be
called on to actually perform these interventions, physicians are likely to
be less supportive. This may also partially explain why psychiatrists, obstetricians,
surgeons, and others who rarely care for terminally ill patients are more
supportive than oncologists.
PRACTICES OF US PHYSICIANS
Numerous studies have documented the practices of US physicians regarding
euthanasia or PAS (Table 4). The
precise proportion of physicians who have received such requests is unclear
because there is significant variation in the reported frequencies. The different
reported rates of requests for euthanasia and PAS may reflect methodological
issues, such as: (1) the differences between mailed and telephone surveys;
(2) the different dates of the surveys, with physicians being more willing
to acknowledge performing these interventions in later years, as the debate
becomes more public and accepted; (3) the different regions of the country,
with those in the West having requests more frequently than those in the New
England or North Central regions43; and (4)
the different investigators, with physicians more willing to acknowledge performing
these interventions when the survey comes from investigators from the same
state or a colleague in the same specialty.15, 30, 32-34,39, 43, 48
However, in general, it appears that oncologists have received many more requests
than nononcologists. Fewer than 20% of nononcologists have received requests
for PAS, while it appears that among oncologists as many as 50% have received
requests for euthanasia or PAS (Table 4). This is probably because oncologists are more likely to care
for dying patients than internists, surgeons, neurologists, or other physicians.
Nevertheless, even among oncologists, the survey results vary considerably,
suggesting residual methodological issues.
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Table 4. Requests for and Performance of Euthanasia and Physician-Assisted
Suicide (PAS) Among American Physicians*
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In general, physicians who have received requests have received few
requests.34, 39, 43, 45
For instance, Meier et al43 report that, overall,
physicians who received requests for PAS received a median of 3 requests (range,
1-100) in their careers and a median of 4 requests (range, 1-50) for euthanasia.
Carver et al45 reported that, among neurologists
who received requests, the mean number of requests for PAS was 7 and was 5
for euthanasia.
Many studies indicate that a small, but definite, proportion of US physicians
have performed euthanasia or PAS, despite its being illegal. Again, the data
provide conflicting evidence on the precise frequency of such interventions,
with reported frequencies varying more than 6-fold even among the best studies
(Table 4). As with requests, oncologists
generally report having performed euthanasia or PAS more frequently. Much
of this variation may be attributable to the reasons already cited, especially
the differences in specialties. However, there is another methodological concern.
The study by Meier et al43 is the only study
to have reported that more US physicians perform euthanasia than PAS. This
finding contrasts with the data showing that US physicians are significantly
more supportive of PAS than euthanasia.15, 20, 25, 29, 37, 47-48
This result may be because physicians were classifying cases of terminating
care as euthanasia. As reported by Emanuel et al,49
despite careful wording, physicians frequently confound euthanasia and terminating
life-sustaining treatments, and this may be more common and harder to control
for in mailed rather than telephone surveys.
When US physicians have performed euthanasia or PAS, they have done
so rarely. Meier et al43 reported that the
median number of PAS cases was 2 (range, 1-25), and the median number of euthanasia
cases also 2 (range, 1-150). A recent survey of oncologists by the American
Society of Clinical Oncology reported that, of those who had performed PAS,
37% had done so only once in their careers, while 18% had done so 5 or more
times.48 Similarly, among the US oncologists
who had performed euthanasia, more than half had done so only once, and just
12% had done so 5 or more times.48
Beyond the rates of requests and performance of euthanasia and PAS,
what do physicians do when they receive a request and when they perform euthanasia
or PAS? Back et al34 reported that initially
76% of physicians increased treatment of physical symptoms, 65% treated depression
and anxiety, and 24% referred the patient for a psychiatric evaluation. Similarly,
Meier et al43 reported that 71% of physicians
responded to requests for euthanasia or PAS by increasing analgesic treatment,
while 30% used fewer life-prolonging therapies and 25% prescribed antidepressants.
Regarding the actual performance of euthanasia and PAS, Meier43 and Emanuel49 and
their colleagues provide similar data, at least as regards PAS (Table 5). They show that, while safeguards are adhered to overall,
there are a myriad of problems. For instance, although most patients initiated
the request for PAS, almost half of them did not repeat the request. Most
important, both studies show that about 5% of patients were unconscious at
the time of death and could not, therefore, provide concurrent consent. More
than 95% of patients had severe symptoms, but according to Meier et al, only
54% had significant pain, while according to Emanuel et al, 84% of the patients
with cancer who received PAS had substantial pain. In 40% to 54% of cases,
the patients were getting hospice care, at least one measure of quality end-of-life
care. Similarly, in many cases, patients who receive PAS had long-term relationships
(>1 year) with their physicians. Finally, there are divergent data, ranging
from 20% to 40%, on what proportion of patients provided with medications
or a prescription ultimately does not use them. Differences in underlying
disease may partially account for differences in the data between these 2
studies; Meier et al provide data on patients with many different terminal
illnesses, whereas Emanuel et al interviewed oncologists and provided data
on patients dying of cancer.
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Table 5. Patients' Attitudes Toward and Experiences With Euthanasia
and Physician-Assisted Suicide (PAS)*
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Two studies have examined the effect on physicians of performing euthanasia
or PAS. Meier et al43 and Emanuel et al49 reported that most physicians were comfortable with
having performed euthanasia or PAS. According to Meier et al, 19% of physicians
were uncomfortable after performing PAS, and 12% were uncomfortable after
performing euthanasia. (This lower proportion of uncomfortableness after performing
euthanasia may reflect that many of these so-called euthanasia cases were
actually cases of terminating life-sustaining treatments.) They also found
that in similar circumstances only 1% would not comply with PAS and 7% would
not comply with euthanasia. Emanuel et al reported that 25% regretted performing
euthanasia or PAS and that 15% had adverse emotional reactions to performing
euthanasia or PAS. At least in the cases reported by Emanuel et al, these
reactions did not seem related to fear of prosecution.
Finally, there is some disagreement about failed PAS attempts. Emanuel
et al49 reported that in 15% of cases PAS failed;
that is, patients were given a prescription or attempted suicide, but did
not die. Ganzini et al52 recently reported
that there had been no failed PAS attempts in Oregon since legalization. The
reports from the first 2 years' experience by the Oregon Health Division,
Portland, also show no failed PAS attempts.53
As Nuland54 notes, the lack of problems with
PAS in these reports from Oregon contrasts with the recently reported Dutch
experience, in which 7% of PAS cases had complications and in 16% it was taking
"longer than expected."55 Ultimately, in 18.4%
of PAS cases in the Netherlands, physicians intervened to administer lethal
medications, converting PAS cases into euthanasia.53
The importance of this for the United States relates to the possibility of
legalizing PAS without legalizing euthanasia, and what is to be done in the
cases of failed PAS. As the data demonstrate, in the Netherlands, the accepted
norm is to administer lethal medications—that is, perform euthanasia—in
cases of failed PAS. This would not be permitted in the United States if euthanasia
remains illegal. If the data from Emanuel et al and the Dutch investigators
are correct, there may be serious dilemmas for physicians if PAS is legalized
but euthanasia is not.
ATTITUDES AND PRACTICES OF US NONPHYSICIAN HEALTH PROFESSIONALS
There have been at least 9 surveys of nonphysician health care professionals
(mostly nurses) regarding euthanasia and PAS (Table 6). 38, 56-64
Overall, these studies are not as rigorous in their methods as the best studies
of physicians or patients. They demonstrate that about half of nonphysician
health professionals support euthanasia or PAS in some circumstances, and
that fewer than one third have received requests for euthanasia or PAS. Again,
the type of religion and the strength of religious beliefs are associated
with support for euthanasia and PAS. The data regarding performance of euthanasia
or PAS by nurses vary widely, with one study showing that about 16% have participated
in euthanasia or PAS, and others showing that fewer than 5% have done so (Table 6).
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Table 6. Attitudes and Experiences of Euthanasia and Physician-Assisted
Suicide (PAS) Among American Nonphysician Health Professionals*
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ATTITUDES AND PRACTICES OF US PATIENTS
Although some studies have examined patients' wishes to hasten death
and suicidal ideation, only a few studies15-16,52-53,65
have actually examined the attitudes and experiences of US patients regarding
euthanasia and PAS (Table 5).
Breitbart et al50 examined patients with human
immunodeficiency virus and acquired immunodeficiency disease syndrome (HIV/AIDS)
in New York City; Ganzini et al51 interviewed
patients with amyotrophic lateral sclerosis in Oregon; and Emanuel et al15 surveyed patients with cancer in Massachusetts. In
addition, there are data reporting on the first 2 years' experience of legalized
PAS in Oregon, involving some 43 cases.53, 65
There are additional data on the practices of euthanasia and PAS among patients
determined to be terminally ill by their physicians.16
Four major conclusions can be drawn from these data.
First, mainly patients with cancer use euthanasia and PAS. Among the
first 43 cases of PAS in Oregon, 72% of the patients had cancer.53
Meier et al43 report that among patients receiving
PAS, 70% had cancer, while among those receiving euthanasia, only 23% had
cancer. These data are comparable to the data from the Netherlands, in which
80% of euthanasia and 78% of PAS cases involved patients with cancer,66 and from the Northern Territory, Australia, where
all 7 patients who received euthanasia when it was briefly legalized had cancer.67
Second, it appears that pain is not a major determinant of interest
in or use of euthanasia or PAS (Table 5). Almost all of these studies—as well as the interviews with
physicians who have administered euthanasia and PAS34, 43—have
shown that pain is not a predictor of patients' interest in euthanasia or
PAS. For instance, among the patients receiving PAS in Oregon, only 1 of 15
had uncontrolled pain.65 Breitbart et al50 reported that pain, pain intensity, and pain-related
functional impairment were not associated with interest in PAS among patients
with HIV/AIDS. Emanuel et al15 reported that
for oncology patients, pain was not associated with personal interest in euthanasia
or PAS. However, they did find that for terminally ill patients, pain was
among the factors associated with personally considering euthanasia or PAS.16
Third, depression, hopelessness, and general psychological distress
are consistently associated with interest in PAS and euthanasia (Table 5). Breitbart et al50
reported that depression and hopelessness were strongly related to interest
in PAS for patients with HIV/AIDS. Emanuel et al15
reported that, for oncology patients and terminally ill patients, depressive
symptoms were associated with personal interest in euthanasia or PAS, such
as discussing these interventions and hoarding drugs for the purpose of PAS.
Ganzini et al51(p968) reported that hopelessness,
but not depression, was associated with "considering taking a prescription
for a medicine whose sole purpose was to end my life."
Fourth, Emanuel et al16 reported that
among terminally ill patients, the extent of caregiving needs was associated
with interest in euthanasia or PAS. Ganzini et al,51
however, reported that there was not an association between the burden of
caring for the patients and whether caregivers supported or opposed a patient's
request for PAS.
Although it is known that PAS and euthanasia occur in a small proportion
of all deaths, what is not known is the precise frequency these interventions
are used. In the Netherlands, 3.4% of all deaths are by euthanasia and PAS,
including involuntary euthanasia.66 In Oregon,
the proportion of all deaths by PAS reported to the Oregon Health Division
is 0.09%.53 Such a low rate raises skepticism
that not all cases of physician-assisted death are reported.54
Emanuel et al16 have reported a rate of 0.4%
among competent terminally ill US patients.
FUTURE EMPIRICAL RESEARCH REGARDING EUTHANASIA AND PAS
There are 6 major areas related to euthanasia and PAS in need of additional
research in the United States. First, there are few data on the relationship
between euthanasia or PAS and the provision of optimal end-of-life care. Are
euthanasia and PAS used as truly last-ditch interventions for patients refractory
to appropriate end-of-life interventions? Or are they used as substitutes
for optimal end-of-life care? The American Society of Clinical Oncology survey
suggested that there was a relationship between not being able to get dying
patients all the care they needed and use of euthanasia and PAS.46
This result needs confirmation. Furthermore, we need to understand what are
the predictors of physicians who come to use euthanasia and PAS only after
trying optimal care, vs those who use these interventions as a substitute.
Is this the result of structural or financial barriers to optimal end-of-life
care, or is it the result of problems on the part of physicians, such as lack
of training in end-of-life care?
Second, there are divergent data on how frequently PAS fails and no
data on what is done when it does fail. If, in the United States, only PAS
will be legalized, what do physicians do when it fails?
Third, there is no information on the short- and long-term effects of
euthanasia and PAS on the surviving family members of the patients.16 Immediately after the interventions, families may
have the psychological need to be supportive of the decision and believe that
the right thing was done. However, with the passage of time, they may have
different views.
Fourth, there are conflicting data on the actual frequency of euthanasia
and PAS. These interventions occur, but how frequently? It may be that conducting
a death certificate follow-back study modeled on the Dutch studies55, 66 will be the best way to obtain accurate
data on the frequency of these interventions, as well as the reasons for the
interventions, the palliative measures taken, and the effects on the family.
Fifth, there are no data on the frequency of nonvoluntary euthanasia
in the United States. In the Netherlands, nonvoluntary euthanasia occurs in
0.7% of all deaths.55 The rate may be higher
in the United States, given the expense and financial problems associated
with end-of-life care.68-69 Issues
of coercion and of performing euthanasia on patients who are not competent
are serious, and there are inadequate data on these events in the United States.
Finally, there are no data on euthanasia and PAS among children. Although
death is rare among children, annually there are several thousand deaths among
children with cancer and HIV/AIDS. These deaths tend to occur after significant
and prolonged illnesses, and symptom management is less than optimal.70 The American Society of Clinical Oncology survey
of US oncologists suggests that there are instances of pediatric euthanasia
or PAS.48 Why these occur and how they are
handled are also important and controversial issues.
Unfortunately, each of these issues is difficult to study because euthanasia
and PAS are rare events, requiring screening of many physicians to identify
just a few cases. Therefore, such studies will be large and expensive.
CONCLUSIONS
During the last decade, there has been a substantial amount of empirical
research conducted on euthanasia and PAS in the United States. This empirical
research has revealed many unexpected findings that have significantly affected
the public debate. Such findings include: (1) Public support for euthanasia
and PAS is closely linked with the reasons patients want these interventions;
most of the public support the interventions only for patients in excruciating
pain. (2) Yet, pain does not appear to be the primary factor motivating patients
to request euthanasia and PAS; depressive symptoms, hopelessness, and other
psychological factors appear to motivate patients' requests for euthanasia
and PAS. Therefore, public support conflicts with the actual facts about patient
interest in euthanasia and PAS. (3) Euthanasia and PAS occur, albeit at a
low rate. Indeed, more than 99% of all dying Americans do not have these interventions,
and even in the Netherlands, more than 96% of all decedents do not have these
interventions.
AUTHOR INFORMATION
Accepted for publication May 1, 2001.
Corresponding author and reprints: Ezekiel J. Emanuel, MD, PhD, Department
of Clinical Bioethics, Warren G. Magnuson Clinical Center, Bldg 10, Room 1C118,
National Institutes of Health, Bethesda, MD 20892-1156.
From the Department of Clinical Bioethics, Warren G. Magnuson Clinical
Center, National Institutes of Health, Bethesda, Md.
REFERENCES
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