Euthanasia and Assisted Suicide:

Issues for Social Work Practice

Ellen L. Csikai, PhD, MPH

ABSTRACT. Whether or not the practices of euthanasia and assisted

suicide are viable as societal options presents a challenging dilemma
for social workers in health care settings. Social workers should prepare
to discuss possible requests for information about these practices in the
context of patient and family decision making in end-of-life situations.
Along with awareness of definitions, current debate, federal, state, pro-
fessional policies, other health care professionals’ attitudes and practic-
es, social workers must examine their own values, attitudes, and prac-
tices in this highly controversial area so that the profession may continue
to enhance quality of life and protect vulnerable populations, such as the
elderly. [Article copies available for a fee from The Haworth Document Deliv-
ery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com
<Website: http://www.haworthpressinc.com>]

KEYWORDS. Assisted suicide, ethics, euthanasia, health care, end-

of-life issues, practice

Social workers have long dealt with ethical issues in the health care
setting, but perhaps none are as challenging as euthanasia and assisted
suicide. Media attention to the practices of Dr. Jack Kevorkian and the
recent U.S. Supreme Court decisions that upheld the constitutionality
of two states’ laws, New York and Washington, prohibiting physician-
assisted suicide has expanded public awareness of the ethical dilem-
mas inherent in the consideration of end-of-life-issues. The fact that
80 percent of patients who die do so in health care institutions adds to

Ellen L. Csikai is Assistant Professor, Stephen F. Austin State University, School

of Social Work, Box 6104–SFA Station, Nacogdoches, TX 75962.
Journal of Gerontological Social Work, Vol. 31(3/4) 1999
E 1999 by The Haworth Press, Inc. All rights reserved. 49
50 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

the urgency of considering issues for patients who increasingly fear

that their final wishes will not be honored and thus be forced to suffer
unnecessarily (Capron, 1996; Thomasma, 1996).
As social workers in health care assist patients and families respond
to the challenges of devastating illnesses, social workers may also
increasingly find themselves responding to requests for information
about end-of-life issues such as euthanasia and assisted suicide. Social
workers need to prepare for these requests by being knowledgeable
about current literature and debates, federal, state and professional
policies, and by examining their own values and attitudes about eutha-
nasia and assisted suicide.

DEFINITIONS AND CURRENT DEBATE

Confusion of the many terms involved in end-of-life decisions often
occurs. Passive euthanasia is the withholding or withdrawing of artifi-
cial life supports or other medical treatment, which may prolong life,
and allowing the patient to die. Physician-assisted suicide refers to the
practice of physicians providing the means (medication or other inter-
ventions) of suicide to a competent patient who is capable of carrying
it out. Active voluntary euthanasia is the case of a physician adminis-
tering the lethal dose of medication to a competent person who explic-
itly requests it. Involuntary euthanasia pertains to the intentional ad-
ministration of medication or other interventions to cause a competent
person’s death, without informed consent or an explicit request. Non-
voluntary euthanasia involves ending the life of a mentally incompe-
tent person who is unaware of what is happening and is not able to
request it or involves a person who is not willing (Asch, 1996; Cohen,
Film, Boyko, Jonsen, & Wood, 1994; Emanuel, 1994; Slome et al.,
1997; Smokowski & Wodarski, 1996).
Passive euthanasia is currently widely practiced utilizing advance
directives of patients, such as living wills and durable powers of
attorney for health care, or decisions of surrogates. This act is not seen
as criminal as the physician is following patients’ wishes or the ‘‘best
interests’’ standard for controlling, most often limiting, medical treat-
ment. The intent of the patient is also understood by all involved in the
case of physician assisted suicide. An example of this practice is the
prescription of a lethal medication to a person capable of swallowing
an overdose. In active voluntary euthanasia, the medical personnel
 Ellen L. Csikai 51

would actually administer the lethal means which causes death after it
is explicitly requested by a patient.
Most of the current debate on active voluntary euthanasia and as-
sisted suicide is defined and conceptualized by physicians, ethicists,
and philosophers with experience and/or interest in examining the
ethical dilemmas involved with these practices. Much of the argument
in favor of permitting euthanasia or assisted suicide appeals to the
concept of autonomy. Individuals define what a good and valuable life
means for them and make their own choices as to how to fulfill their
lives. This view also includes the conception of a good death as within
the limits of autonomy, as society recognizes rights to refuse medical
treatment and end life when the treatment would not be consistent with
the view of a good life (Emanuel, 1994). If one accepts this view, then
active voluntary euthanasia and assisted suicide are not ethically dif-
ferent from the utilization of advance directives in terminating life-
sustaining medical care. Continuing to live for some may cause more
pain and suffering than death would and proponents argue that indi-
vidual well-being in the form of relief of intolerable suffering due to a
terminal or incurable and tremendously debilitating disease process
through assisted suicide is legitimate (Kamisar, 1993). Another stated
reason to allow for these practices is that society has a responsibility
from a community standpoint to offer assisted suicide as a last resort,
at the end of a continuum of pain relief, when suffering cannot be
alleviated by standard means; specifically, identifying the use of hos-
pice services before considering assisted suicide (Miller, 1997). In the
hospice setting, pain relief is generally in the form of medication and
is supervised by hospital staff.
Along these lines, it has been recommended that decisions about the
use of active euthanasia and assisted suicide should be made using a
case approach, by people (family and medical professionals) that
know that person well and this may indeed be an appropriate response
to protect against abuse of the practices. Quill (1991), a hospice physi-
cian, described the case of ‘‘Diane,’’ where relief from pain and provi-
sion of a ‘‘good death’’ was not possible by any other means other
than by assisting death. However, he did note that he saw this action as
a failure, unavoidable, and as an exceptional case, but it was a case
which was handled competently and humanely (Brody, 1992). Offer-
ing assisted suicide under very controlled circumstances would be
better than continuing the activity in secrecy (Bachman et al., 1996).
52 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

Euthanasia and assisted suicide is often seen as part of the physicians’

professional duty and consistent with the goals of medicine which
include ‘‘healing, promoting health and helping patients achieve a
peaceful death’’ (Miller & Brody, 1995, p. 12). In a comparable man-
ner, discussing these two practices as part of a full spectrum of poten-
tial options, including acute, home health, long-term, and hospice
care, to all patients, if patients request the information, as well as
ensuring access to each alternative, so that patients may make in-
formed choices, may be viewed as consistent with the goals and pur-
poses of social work.
Callahan (1992) takes issue with the autonomy argument stating that
active euthanasia is more than a matter of self-determination. It is ‘‘a
mutual, social decision between two people [patient and physician] the
one to be killed and the other to do the killing’’ (p. 52). Some of the
strongest opposition of physician-assisted suicide center around the
Hippocratic oath of physicians to ‘‘do no harm,’’ which prohibits the
prescription of lethal doses of medications to patients. The relief of
pain, most often seen as a primary reason for requesting euthanasia or
assisted suicide, should be administered through standard medical care,
with the recognition that increased education regarding pain manage-
ment and hospice care among physicians may be needed (Brody, 1992;
Capron, 1996; Quill, Cassel, & Meier, 1992; Thomasma, 1996).
A fear in the medical community also exists that trust in physicians
would be undermined if they have the social sanction to intentionally
cause death (Miller & Brody, 1995) Another related concern often
stated in the literature is if the practice of assisted suicide is permitted
that we may be on a ‘‘slippery slope.’’ ‘‘The slippery slope’’ concept
refers to the belief that by allowing assisted suicide as a voluntary
choice that this will then lead to permissibility of active voluntary
euthanasia and to the even more unacceptable practices of involuntary
and nonvoluntary euthanasia. Thus, there may not be a free choice, or
a choice at all, especially for those disenfranchised and vulnerable,
such as persons with AIDS or the elderly, in our society. Who will
make the decision of whose life is valuable and worth spending health
care dollars on and whose life is expendable? Are these decisions to be
left to the impersonal methods and constraints of managed care offi-
cials who are increasingly scrutinizing medical care to reduce costs?
For these vulnerable people, a risk also exists for coercion or sugges-
tion of obligation to accept euthanasia if it is determined that their life
 Ellen L. Csikai 53

is not of value to society (D’Oronzio, 1997; Emanuel, 1994; Kamisar,

1993; Koenig, 1993) in order to relieve society of the burden or to
spare family of perceived financial hardship and emotional distress
that they may incur during the course of the patient’s care.
Despite the belief that the primary purpose in allowing the practices
of euthanasia and assisted suicide is to relieve pain in the terminally
ill, data from the Netherlands, in a study of 405 physicians, the Rem-
melink Commission (Emanuel, 1994; Van der Maas, Van Delden,
Pinjnenborg & Looman, 1991) reported that loss of dignity was the
primary reasons given by patients requesting assistance in death. In a
study of 828 physicians (Back, Wallace, Starks, & Pearlman, 1996),
case information regarding the last one or two of the physicians’
patients who had made a request for euthanasia or assisted suicide was
gathered on a total of 207 different patients. Examination of this data
revealed that the physicians perceived that future loss of control, being
a burden, strain on others for some or all of their personal care and loss
of dignity were most often what prompted the request for euthanasia
or assisted suicide. However, patients requested euthanasia, rather
than assisted suicide, more often if they were experiencing severe
pain, physical discomfort, severe suffering, dependency on others, or
confinement to bed. The physicians responded most often by further
discussing the request with the patient and increasing treatment of
physical symptoms. So by simply addressing issues of pain control,
many patients’ fears and concerns about the end of their lives will not
be eliminated. It is precisely in this type of situation that social work-
ers can utilize their skills to intervene with patients, families, and
health care professionals to encourage, coordinate, and facilitate mul-
tidisciplinary discussion about issues important to patients and quality
of life.
Upon further examination of arguments in favor of allowing eutha-
nasia and assisted suicide, it seems that qualifiers often accompany the
attitude that these practices should be allowed. In the Netherlands,
where euthanasia is permitted, an assumption exists that euthanasia
can be controlled or monitored. Guidelines to protect physicians from
prosecution are in place which include that: euthanasia must be explic-
itly and repeatedly requested by the patient (no doubt that the patient
wants to die); the mental and physical suffering is severe with no
prospect for relief; the patient’s decision is informed, free, and endur-
ing; all other options for care have been utilized or refused by the
54 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

patients; and that two physicians must be in agreement (Thomasma,

1996). The Remmelik Commission study found that in more than 40
percent of euthanasia cases, the criteria was not adhered to; with
physicians administering lethal drug overdoses to patients who were
not fully competent to request euthanasia (Van der Maas et al., 1991).
Still the view that there may be situations where euthanasia or assisted
suicide are appropriate does exist. In a study of physicians in the state
of Washington, 88 percent of 343 physicians who believed that both
euthanasia and assisted suicide were ethical in some situations, further
indicated that a poor quality of life, despite adequate pain control
might justify the use of these practices and 31 percent agreed that if a
patient has a good quality of life at present, but had an illness that
would cause a severe mental or physical deterioration in the future,
assisting in death may be appropriate (Cohen et al., 1994). A glaring
example of the inherent ethical and value conflicts that euthanasia and
assisted suicide pose is that 51 percent of these physicians also thought
that a patient’s pain should be beyond control in order to warrant the
practices (Cohen et al., 1994). Favored safeguards for the practices
among the 432 physicians who agreed with the legalization of eutha-
nasia and assisted suicide were that the patient’s request should be
witnessed by a person(s) who will not benefit from the patient’s death,
determination of competency of the patient and the agreement of two
physicians with the decision to engage in euthanasia or assisted sui-
cide (Cohen et al., 1994).

POLICIES:
FEDERAL, STATE, PROFESSIONAL
No federal policy regarding the practices of physician-assisted sui-
cide or active euthanasia exists. However, a ban against using any
federal funds, including medicaid money, to pay for physician-assisted
suicide was recently signed into law by President Clinton. Oregon is
the only state that has a law allowing assisted suicide under some
circumstances; it was passed as an initiative by voters in 1994. The
Oregon law since was declared unconstitutional by a Federal district
court and has an appeal pending. A total of 33 states have statutes
prohibiting assisted suicide. In 12 states, assisted suicide is prohibited
by common-law doctrine which implies that suicide is a form of homi-
cide. In the remaining 4 states, the status is unclear; no law exists,
 Ellen L. Csikai 55

common-law doctrine is not recognized and no judicial decisions exist

on whether assisted suicide is a form of homicide (Greenhouse, 1997).
The use of advance directives, through which passive euthanasia is
sanctioned, has federal promotion through the Patient Self-Determina-
tion Act (1990), and has widespread legal support in most states.
While we are provided with legal limitations regarding euthanasia and
assisted suicide, we are not given any further guidance on how to
proceed in the inevitable cases that will arise.
Major national associations of various health care professionals,
such as the American Medical Association (AMA), the American Nurses
Association, The National Hospice Organization (NHO), and the Acad-
emy of Hospice Physicians all oppose the legalization of physician-as-
sisted suicide. Participation by any active means to end a patient’s life
is not sanctioned, according to the AMA Position Statement (1995).
The role of the physician is to help those with a terminal illness by
providing ‘‘compassionate care, comfort, and support,’’ not by caus-
ing death. The AMA (1995) points to an ‘‘overriding public interest in
protecting vulnerable citizens from the irreparable finality of death.’’
The AMA has recently adopted its first policy for end-of-life care
which contains a switch from preserving life at all costs to a position
of following patients’ wishes to have a dignified death (opposition to
assisted suicide is reinforced in the policy) (Mauro, 1997). The 1995
ANA position statement asserts that ‘‘the nurse does no act deliberate-
ly to terminate the life of any person,’’ and specifically states that it is
unethical to participate in the practice of assisted suicide. All of these
professional organizations aggressively support the use of educational
efforts to further the use of adequate pain control and hospice care
programs. The NHO (1995) opposes euthanasia and assisted suicide
and additionally promotes expansion of hospice services to people
who are not terminally ill, but have chronic conditions with a need for
pain management.

NASW POLICY STATEMENT

According to the NASW policy statement on End-of-Life Deci-
sions, the primary principle to guide social workers is client self-deter-
mination. ‘‘Choice should be intrinsic to all aspects of life and death’’
(NASW, 1996, p. 61). In order to maximize self-determination, social
workers must be well informed of and comply with the laws of their
56 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

states concerning end-of-life decisions, including living wills, durable

powers of attorney for health care, and laws concerning physician
assisted suicide. Social workers in health care settings are directed to
facilitate communication between the health care team and patients
and families so that concerns about appropriate medical treatment may
be addressed and resolved in a responsible manner (NASW, 1996).
The directive given here is one not to be taken lightly. Social workers
can make a significant contribution to discussions about end-of-life
issues as the profession that has as a primary purpose enhancing
quality of life. To accomplish this purpose, all those involved with
patients need to take part in the discussion. Furthermore, social work-
ers should take the lead to initiate education and dialogue regarding
end-of-life issues and the ethical dilemmas they pose among profes-
sionals in their employment setting and among community members.
NASW policy also dictates that in discussing the full array of op-
tions available to patients and families in an end-of-life situation
(counseling, advance directives, nursing home placement, hospice ser-
vices, physician assisted suicide if allowable by law), social workers
are not to promote any means in particular. As a primary value for
social workers, respect for self-determination already dictates that
social workers not promote any particular alternatives, no matter what
the situation, so of course patients should have free choice which
should be safeguarded. The NASW policy does not take a stand on
euthanasia and assisted suicide, but implies that social workers may be
involved in discussion of the practices in the eventuality that it may be
legalized; but what should social workers do in the meantime? It
seems as if fear of open discussion as a profession is perpetuated. Social
workers should receive the sanction necessary to further explore is-
sues that are important to our patients and families no matter how
emotionally explosive these issues might be so that patients may make
informed decisions. As in all other matters, social workers should not
attempt to influence patients’ choices.
Also according to the NASW policy regarding end-of-life decisions
(1996), social workers should be allowed to excuse themselves from
discussions of assisted suicide and related matters with patient/fami-
lies if uncomfortable with ideas that may contradict their personal
beliefs and values and if they do not feel they can approach the situa-
tion objectively. They further have the ethical responsibility to refer
the patients/families to another professional who is able to discuss
 Ellen L. Csikai 57

such issues with them. A prerequisite to referring elsewhere is aware-

ness of one’s own values; however, if discussion is stifled, how can
social workers discern their preferences and come to balance both
personal and professional views? Lack of information is not a valid
reason to refer a patient to another social worker.
The end-of-life policy additionally asserts that it is inappropriate for
social workers to participate in the act of performing assisted suicide
while in their professional capacity (as they may be criminally liable).
Social workers may be present, if legal in their state, during an assisted
suicide if requested by the patient (NASW, 1996). Supporting patients
and their families is an essential part of social workers’ roles and
cannot be abandoned when it is needed the most.

PROFESSIONAL ATTITUDES AND PRACTICES

Despite the widespread disapproval of legalization of assisted sui-
cide by various medical organizations, a recent public opinion survey
revealed that 57 percent of Americans polled believe that physician-
assisted suicide should be allowed (Mauro, 1997). Two-thirds of 998
Michigan adults when given a choice between legalization of assisted
suicide or an explicit ban favored legalization (Bachman et al.,
1996). A 1994 study of Washington State physicians showed that a
majority of physicians believe that assisted suicide should be legal in
some form and in fact is occurring; ‘‘driven underground’’ by the
current laws (Cohen et al., 1994). Additionally, in a separate study,
12 percent of practicing physicians in Washington State (N = 828)
reported that they have had at least one patient request for assisted
suicide and 4 percent had at least one request for euthanasia in the
previous year (Back et al., 1996). Further, physicians provided a pre-
scription for lethal medication to 24 percent of patients who requested
it (Back et al., 1996). In a study of critical care nurses, 17 percent
reported that they had received requests to perform assisted suicide
and 16 percent had engaged in the practice during their career, includ-
ing 8 percent within the previous year (Asch, 1996). Sixty-two percent
of the nurses who had performed the practice had done so at least one
time without a physician’s request (Asch, 1996). Despite the strong
positions of the AMA and ANA, assisted suicide is being practiced,
which suggests that professionals are being influenced by the difficult
situations of patients and by their own attitudes toward care at the end-
58 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

of-life. Callahan (1992) has stated his belief that physicians who par-
ticipate in euthanasia do so according to their own personal value
system, which in turn affects the helping relationship and possibly, the
options presented and considered in end-of-life decision making situa-
tions.

IMPLICATIONS FOR SOCIAL WORK PRACTICE

Due to current rapid advances in medicine, health care social work-
ers have increased exposure to end-of-life situations and the accompa-
nying ethical dilemmas. Social workers are at the heart of emotional
in-depth discussions with patients and families regarding these issues.
They assist in translating the medical jargon into understandable terms
for patients/families and in distinguishing among options for care that
are available to them. Such matters demand effective use of social
workers’ knowledge of family dynamics, unique skills in facilitating
communication and assistance in decision making for patients and
families (Csikai, 1997). It has been noted that people want more con-
trol over their own death (Huber, Cox, & Edelen, 1992) and in demon-
stration of respect for self-determination, social workers have an ethi-
cal responsibility to advocate for the patient’s choice.
Along with having regard for their profession’s values and codes of
ethics, every professional also holds certain societal, cultural, and
personal values. Many values are part of the subconscious (as a result
of the professions’ socialization process), and others emerge through
familial, social, and other experiences, so undoubtedly these factors
play a role in how we work with patients and families. Social workers
need to engage in continuous examination of their attitudes regarding
difficult issues and evaluate whether these attitudes are interfering
with effective practice. They must be careful to acknowledge that their
values may be different than clients’ values and that self-determina-
tion precludes pressuring clients to make decisions that correspond to
the social workers’ values (Gelman, 1986; Mitchell, 1996; Wesley, 1996).
Regarding end-of-life issues, potentially including euthanasia and
assisted suicide, if social workers are uncomfortable in discussing these
matters, NASW policy dictates that social workers refer the patient/
family to another professional. However, what implications does this
have for practice situations? How will this affect the helping relation-
ship with that patient who has developed a trust in the practitioner? Is
 Ellen L. Csikai 59

social work to establish a specialty in discussions about death? It may

not be feasible, such as in the case of a rural hospital where only one
social worker may be employed, to transfer the case to someone else.
Consider the case of a daughter of an elderly man, newly diagnosed
with terminal brain cancer, who seeks the assistance of the hospital
social worker because her father is suggesting that he wants to be
assisted in dying. It would be inappropriate as the social worker to
state that you cannot see him or assist her at that point because assisted
suicide is illegal, unethical, and you are not comfortable discussing it
or to refer her to a colleague. The professional response would require
that the social worker conduct a thorough assessment of the situation;
talk to patient, family, other health care professionals and others who
are close to patient, possibly friends and clergy. Open communication
is necessary for assessing the fears and concerns they may have and
explore potential options for treatment. No doubt this is a highly
emotional time for patient and all involved. Through discussion the
social worker may find out that assisted suicide is not what he really
desired. He may have needed the reassurance of his family that they
will support and care for him throughout the terminal stages of the
disease. He may also have needed to hear from his physician what to
expect in the course of the disease and how he will be made comfort-
able, if necessary. Social workers, in fulfilling their obligation to assist
people in reaching their potential and in their pursuit of the highest
quality of life possible, cannot deny assisting people in times of crisis,
especially as times of crisis are opportunities for emotional growth. To
cut off discussion before it begins would be not only unprofessional,
but also unethical.
Additionally, social workers need to be an integral part of team
discussions in health care settings with patients who request euthana-
sia and assisted suicide, whether it is legal in their state or not. As the
practice is taking place, however secretly, physicians and nurses
should also feel they have the option to collaborate with other profes-
sionals to evaluate the patient’s emotional state and family situation
that may be influencing their request, instead of acting alone. In quali-
tative information gathered from a study of Washington physicians
who had received requests for euthanasia or assisted suicide, the phy-
sicians reported that they are reluctant to consult with colleagues due
to concerns about confidentiality or discomfort with the issue. One
physician stated that he only discussed with a colleague after the
60 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

patient had died (Back et al., 1996). Social workers can take the lead in
opening the lines of communication among health care professionals
and creating a safe and confidential environment for open expression
of a wide range of views and opinions. Regarding specific cases,
social workers can assist by providing an in-depth assessment of the
patient/family situation and the environmental conditions or pressures
that may be prompting a request for assistance in death. Attention to
psychosocial factors may uncover true reasons for the request, such as
not wanting to burden the family, which could suggest possible re-
sources that may be needed by the patients/families to assist in over-
coming these difficulties. Open family discussion with medical per-
sonnel may alleviate fears and concerns patients may have about the
terminal stages of their illnesses. The NASW policy statement on
end-of-life decisions leaves the door open for participation in discus-
sions and practice of assisted suicide with patients and families (if
legalized); therefore such discussion is imperative in order to fulfill
our professional mandate of supporting and enhancing social function-
ing, respecting dignity, individuality and free choice. Even though not
permitted at this point in any state, social workers still need to respond
as openly as possible to discussion about issues important to patients
and families that they work with and who are in such emotional
distress as to consider such measures.
Further examining our own personal attitudes and values in end-of-
life ethical issues can only strengthen the practice of social workers in
the health care setting. Gelman (1986) asserts that in life and death
matters, codes of ethics/conduct provide insufficient direction. Focus
on constructing practice guidelines for examining end-of-life issues,
including euthanasia and assisted suicide, may serve to minimize the
impact that social workers’ own personal values may have in these
situations and possibly decrease situations in which social workers are
uncomfortable.
In order to develop such practice guidelines, research is needed that
will specifically address social workers’ attitudes about euthanasia and
assisted suicide, how often social workers receive requests for assis-
tance in dying, and how social workers respond in these cases. Differ-
ent settings, including hospital, home health, hospice, and long-term
care, should be investigated as to the impact of differential experiences
in health care on social workers’ attitudes. Armed with this knowledge
guidelines can serve also to further explore safeguards for allowing
 Ellen L. Csikai 61

euthanasia or assisted suicide. Mechanisms may be built in for patient

discussions facilitated by social workers familiar with the situation,
case conferences initiated and conducted by social workers; which
would include all of the health professionals involved, or automatic
referrals to ethics committees or for ethics consultation, an arena where
social workers are frequently represented (Csikai, 1997).

CONCLUSIONS

While the U.S. Supreme Court failed to assert a constitutionally

protected right to assistance in suicide, Chief Justice Rehnquist stated,
‘‘our [the Court] holding permits this debate [over assisted suicide] to
continue, as it should in a democratic society’’ (Excerpts, 1997, p. A18).
According to Justice Souter, ‘‘the court should stay its hand to allow
reasonable legislative consideration’’ (Excerpts, 1997, p. A18). Also,
Justice Breyer contended that he did not believe that the Court ‘‘need
or now should decide whether or not such a right [to have assistance in
suicide] is fundamental’’ (Excerpts, 1997, p. A18). Having reaffirmed
the need for continued discussion about a range of end-of-life issues,
how is this best done?
Social policy formulation regarding the issues of euthanasia and
assisted suicide should include participation of a wide range of disci-
plines in the health care setting. Social workers can make a valuable
contribution in the discussion of whether or not allowing euthanasia
and assisted suicide is viable as a societal option. They have the
uncommon advantage of being historical advocates of self-determina-
tion in policy as well as individual matters. Traditional emphasis on
considering people in their social environment also gives social work-
ers a unique position from which to facilitate a contextual examination
of ethical issues in end-of-life care as these issues affect the individual,
family, community, and society. If euthanasia and assisted suicide are
legalized, social workers also need to voice their concerns about po-
tential risks for abuse and contribute to policies in a manner that will
protect vulnerable populations. As the debate around end-of-life is-
sues, including the practices of euthanasia and assisted suicide is far
from over, social workers have the opportunity to make a significant
contribution in the scope and direction of these discussions, especially
by knowing where they stand on the issue.
62 JOURNAL OF GERONTOLOGICAL SOCIAL WORK

REFERENCES

Asch, D. A. (1996). The Role of Critical Care Nurses in Euthanasia and Assisted
Suicide. The New England Journal of Medicine, 334(21), 1374-1379.
Anderson, J. G. & Caddell, D. P. (1993). Attitudes of Medical Professionals Toward
Euthanasia. Social Science and Medicine, 17(1), 105-114.
Bachman, J. G., Alcser, K. H., Doukas, D. J., Lichtenstein, R. L., Corning, A. D., &
Brody, H. (1996). The New England Journal of Medicine, 334(5), 303-309.
Back, A. L., Wallace, J. I., Starks, H., & Pearlman, R. A. (1996). Physician-Assisted
Suicide and Euthanasia in Washington State: Patient Requests and Physician
Responses. Journal of the American Medical Association, 275(12), 919-925.
Brody, H. (1992). Assisted Death–A Compassionate Response to a Medical Failure.
The New England Journal of Medicine, 327(19), 1384-1388.
Callahan, D. (1992). When Self-Determination Runs Amok. Hastings Center Report,
22(2), 52-55.
Capron, A. (1996). Legalizing Physician-Aided Death. Cambridge Quarterly of
Healthcare Ethics, 5, 10-23.
Cohen, J. S., Film, S. D., Boyko, E. J., Jonsen, A.R., & Wood, R. W. (1994).
Attitudes Toward Assisted Suicide and Euthanasia Among Physicians in Wash-
ington State. The New England Journal of Medicine, 331(2), 89-94.
Csikai, E. L. (1997). Social Workers’ Participation on Hospital Ethics Committees:
An Assessment of Involvement and Satisfaction. Arete, 22(1), 1-13.
D’Oronzio, J. C. (1997). Rappelling on the Slippery Slope: Negotiating Public Policy
for Physician-Assisted Death. Cambridge Quarterly of Healthcare Ethics, 6(1),
113-117.
Emanuel, E. J. (1994). Euthanasia: Historical, Ethical, and Empiric Perspectives.
Archives of Internal Medicine, 154(5), 1890-1901.
Excerpts From Decision that Assisted Suicide Bans Are Constitutional (1997, June
27). The New York Times. p. A18.
Gelman, S. (1986). Life vs. Death: The Value of Ethical Uncertainty. Health and
Social Work, 11(2), 118-125.
Greenhouse, L. (1997, June 27). Court, 9-0, An Issue that Won’t Die. The New York
Times, p. Al, A19.
Huber, R., Cox, V. M., & Edelen, W. (1992). Right-to-Die Responses from a Random
Sample of 200. The Hospice Journal, 8(3), 1-19.
Kamisar, Y. (1993). Are Laws Against Assisted Suicide Unconstitutional? Hastings
Center Report, 23(3), 32-41.
Koenig, H. G. (1993). Legalizing Physician-Assisted Suicide: Some Thoughts and
Concerns. Journal of Family Practice, 37(2), 171-179.
Mauro, T. (1997, June 27). Assisted Suicide Ban Upheld: But State Can Enact New
Laws. USA Today. p. 1A, 4A.
Miller, F. G. & Brody, H. (1995). Professional Integrity and Physician-Assisted
Suicide. Hastings Center Report, 25(3), 8-17.
Mitchell, C. (1996). Assisted Suicide: A Conflict of Social Work Values. Social Work
and Christianity, 23(2), 102-114.
 Ellen L. Csikai 63

NASW, (1996). Client Self-Determination in End-of-Life Issues. Social Work

Speaks. Washington, DC: NASW Press.
Quill, T. E. (1991). Death and dignity: A Case of Individualized Decision Making.
The New England Journal of Medicine, 324, 691-694.
Quill, T. E., Cassel, C. K., & Meier, D. E. (1992). Care of the Hopelessly Ill:
Proposed Clinical Criteria for Physician-Assisted Suicide. The New England
Journal of Medicine, 327(19), 1380-1384.
Slome, L. R., Mitchell, T. F., Charlebois, E., Benevedes, J. M., & Abrams, D. I.
(1997). Physician-Assisted Suicide and Patients with Human Immunodeficiency
Virus Disease. The New England Journal of Medicine, 336(6), 417-421.
Smokowski, P. R. & Wodarski, J. S. (1996). Euthanasia and Physician-Assisted
Suicide: A Social Work Update. Social Work in Health Care, 23(1), 53-65.
Thomasma, D. C. (1996). An Analysis of Arguments for and Against Euthanasia and
Assisted Suicide: Part One. Cambridge Quarterly of Healthcare Ethics, 5, 62-76.
Van der Maas, P. J., van Delden, J. J. M., Pinjnenborg, L., & Looman, C. W. N.
(1991). Euthanasia and Other Medical Decisions Concerning the End-of-Life.
Lancet, 338, 669-674.
Wesley, C. A. (1996). Social Work and End-of-Life Decisions: Self-Determination
and the Common Good. Health and Social Work, 21(2), 115-121.

RECEIVED: 03/02/98
REVIEWED: 03/03/98
ACCEPTED: 06/16/98
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64 JOURNAL OF GERONTOLOGICAL SOCIAL WORK