Dr. Atul Gawande: Make End Of Life More Humane

Found this article on NPR’s website I found to be interesting from the doctor’s point-of-view. Dr. Atul Gawande, a surgeon and staff writer foe the New Yorker magazine, began researching hospice and end-of-life care options because he says he didn’t know how to broach the subject of death with his terminally ill patients. He writes about the difficulties faced by medical professionals who must decide when to stop medical interventions and focus on improving the final days of life in his article “Letting Go” in the Aug. 2 New Yorker.

Gawande talks about the need or medical professionals to know how to help a dying patient achieve what’s most important to them. He tells Fresh Air‘s Terry Gross that physicians are hesitant to tell patients that there’s nothing else they can do, even if statistics show procedures are unlikely to work.

The use of directives is essential, as well as conversations with family members to understand what their options are and honor the wishes of the patient.

Advance Directives: in a nutshell

Advance Directives. What are they?

There are many types of ADVANCE DIRECTIVES. Below is a list of types of advance directives, including The Patient Self-determination Act or PSDA.

Advance directive is the general term that refers to a person’s request (oral and/or written) concerning health care, should he or she become incompetent. There are two main documents in an advance directive: a living will and a durable power of attorney for health care.

LIVING WILLS A living will is one part of an advance directive. It is a document that outlines a patient’s preferences about end-of-life medical treatments in the event that he or she is unable to communicate or make his or her own decisions. Laws regulating living wills vary from state to state. For example, thirty-one states did not allow the withdrawal of life support from pregnant patients in 2004. Thus, a pregnant woman’s living will could not be honored in those states if the living will asked for the withholding or withdrawal of life support.

Living wills enable people to list the types of medical treatments they want or do not want. It is therefore important for an individual contemplating a living will to know what these treatments involve. Some examples of life-prolonging treatments patients should consider when preparing a living will include cardiopulmonary resuscitation (CPR), mechanical ventilation, artificial nutrition and hydration, and kidney dialysis.

DURABLE POWER OF ATTORNEY FOR HEALTH CARE A durable power of attorney for health care, also called a medical power of attorney, is another part of an advance directive. It designates a health care agent or proxy authorized to make medical treatment decisions on behalf of a patient who can no longer make these decisions, Advance health-care directivefor himself or herself.

ADDITIONAL INSTRUCTIONS IN ADVANCE DIRECTIVES Some living wills contain a provision for the withdrawal of nutrition and hydration.

COMBINED ADVANCE DIRECTIVE LAWS Some states have separate laws that govern living wills and durable powers of attorney for health care. The National Conference of State Legislatures (NCSL) and the Center to Improve Care of the Dying (CICD) believe that rather than having separate laws for these two documents, states should combine right-to-die laws into a single statute. By September 2004, twenty-two states had done just that. (See Table 7.2.) Of these states, Alabama, Alaska, Delaware, Hawaii, Maine, Mississippi, and New Mexico had also adopted the Uniform HealthCare Decisions Act (UHCDA) as a model.

The UHCDA has been recommended by the NCSL and the CICD as a model law because it is simple and comprehensive. It contains provisions governing living wills and durable powers of attorney, as well as limits on an agent’s powers. The law permits instructions regarding one’s future health care to be either written or oral. States using the law as a model may adopt the optional combined directive, which does not require witnesses to the document. It further enables individuals to express their preferences about organ donation and to designate a primary physician. If a state has a comity provision, it has legislation specifically requiring that another state’s living will, a health care power of attorney, or both, be honored within their borders.

IMPORTANCE OF COMMUNICATION FOR END-OF-LIFE CARE. Sometimes knowing things such as the patient’s religious beliefs and values can be important for the proxy when speaking for the patient’s interests. The Center for Health Law and Ethics at the University of New Mexico has devised a values questionnaire to help people examine their attitudes about issues related to illness, health care, and dying. It may serve as a valuable tool to guide discussions between the patient and the proxy, as well as among family members.

When preparing an advance directive, it is vitally important for the family and proxy to fully understand the care and measures that are wanted. Even when a patient has a living will calling for no “heroic measures,” if the family demands such medical intervention, it is likely that the hospital or doctor will comply with the family’s wishes rather than risk a lawsuit.

THE PATIENT SELF_DETERMINATION ACT.  In 1990 Congress enacted the Patient Self-Determination Act (PSDA) as part of the Omnibus Budget Reconciliation Act of 1990 (PL 101-508). This legislation was intended to “reinforce individuals’ constitutional right to determine their final health care.” The PSDA took effect on December 1,1991. It requires all health care providers participating in Medicare (a program of the federal government through which people age sixty-five and older receive health insurance) and Medicaid (a program run by the federal and state governments to provide health insurance to people younger than sixty-five years of age who cannot afford to pay for private health insurance) to provide all patients over age eighteen with the following written information:

The patient’s rights under the law to participate in decisions about his or her medical care, including the right to accept or refuse treatments

The patient’s right under state law to complete advance directives, which will be documented in his or her medical records

The health care provider’s policies honoring these rights

Providers include hospitals, nursing homes, home health care providers, hospices, and health maintenance organizations (HMOs), but not outpatient-service providers or emergency medical personnel. The PSDA requires health care providers to educate their staff and the community about advance directives. It also prohibits hospital personnel from discriminating against patients based on whether they have an advance directive. (Patients are informed that having an advance directive is not a prerequisite to receiving medical care.)

[Source: Library Index.com]

PSDA PROVIDERS

Providers of PSDA include hospitals, nursing homes, home health care providers, hospices, and health maintenance organizations (HMOs), but not outpatient-service providers or emergency medical personnel.

Read more: Advance Directives – The Patient Self-determination Act – Health, Care, Providers, Advance, Patient, Medical, Patients, and Age http://www.libraryindex.com/pages/3133/Advance-Directives-PATIENT-SELF-DETERMINATION-ACT.html#ixzz0vS8ZffWg

Advance Directives: Implications for critical care

The Cruzan case and passage of the Patient Self-Determination Act have led to an ethical and legal recognition of advance directives, and therefore, critical care practitioners must be familiar with these documents. A living will is a mechanism by which patients can communicate their desires for medical treatment at the end of life. However, the condition that patients be in a “terminal condition,” the inability to predict every possible clinical circumstance, and linguistic vagueness have limited the usefulness of living wills. The durable power of attorney for health care overcomes the inherent restrictive weaknesses of living wills, because informed decisions are made by people based on their knowledge of the patient’s beliefs and the nuance of the clinical scenario. A concern with this advance directive is that some patients may not know a suitable person to appoint or that the chosen agent may not be available. CONCLUSIONS: It is recommended the execution of both a living will and a durable power of attorney for health care to provide the best assurance that patients’ desires concerning medical treatments will be respected.

Source: Crit Care Med  1992 Jul;20(7):1027-31

Myths and The Double Effect: Terminal Sedation

As I was looking at resources for this subject there were no shortage of heated opinions from Right to Life individuals, Catholic organizations and Individuals and people with more conservative views of who gets to choose end-of-life matters. I read many opinions of medical staff and people and families that had actually gone through the process (read post Sedation A hard choice for a comfortable death in the case studies category: https://endoflifeissuesdebate.wordpress.com/2010/07/23/sedation-a-hard-choice-for-a-comfortable-death/). I agree that it is not an easy decision and many hard liners fall on the side of religious dogma. I look to the experience for the individual. How are we treating suffering people when we deny them the decision of what to do with their body at the end of their life.

I believe people need more information and honest conversation about death and dying early in life. We need to engage in a health dialogue of what is inevitable for all of us, to have.

As medical technology gets better and better we can now keep people alive far beyond where we could before. Far beyond what many believe is humane. Dying brings out many divided family issues and beliefs, many of which may be opposed to the wishes of the patient. This is why directives are important to have and beyond that, conversations should be had with family members well before an individual gets to the point of having to deal with it. This helps the family act in accordance with the wishes of their loved ones without guilt. They are free to experience the process of death powerfully and lovingly.

I want to begin to dispel some of the myth I have seen about end-of-life issues.The rise of palliative sedation gives many peace of mind that their last days will be spent as comfortable as possible and administered and monitored by competent, empathetic medical professionals.

Thanks to great advances in pain management, many seriously ill and terminally-ill patients can be made comfortable during the final days of an illness.  For some, however, suffering may become extreme. While care-teams will always place the most emphasis on moderating discomfort while attempting the best possible quality of life for terminal patients, certain patients may not respond without very high doses of medication.  It is in these circumstances where physicians may talk about something called the “double effect” of pain medication, or in rare circumstances, about using terminal sedation.  It is hoped that the ill person has discussed what measures should be taken in advance with their health care proxy, or they have stated their wishes in a living will. But to prepare for these discussions, it is important to know what these terms mean:

The “Double Effect”:
The “Double effect” has been defined in medical journals as:  “the administration of opioids or sedative drugs with the expressed purpose of relieving pain and suffering in a dying patient.   The unintended consequence may be that these medications might cause either respiratory depression or in extreme sedation, might cause to hasten a patient’s death.”  What does this mean?  In the simplest terms it means that the medication required to abate suffering cannot be given without the probable result of hastening death. While this may sound vague and quasi-discomforting, it is a legal, medically accepted practice, as long as the intention is only to relieve suffering and not cause death.  The death is attributed to the disease or complications of the disease, combined in some circumstances with the withdrawal of life-sustaining treatments such as intravenous liquids, nutrition and artificial respiration.  While the patient need not be unconscious during this process, unconsciousness is often the result

Terminal sedation:
In rare cases some patients who are very ill do not respond to pain medications or may be suffering in other ways that make comfort impossible.  In these circumstances there is a last resort therapy that can be used: terminal sedation.  With terminal sedation, a patient will be given medications that induce sleep or unconsciousness until such time as death occurs as a result of the underlying illness or disease.  These measures are often accompanied by the withholding of artificial life supports like intravenous feeding and artificial respiration. Like the use of medications that cause a “double effect,” the intention with terminal sedation must be to relieve suffering only, not to cause death.

Bill Moyers “On Our Own Terms. Moyers on Dying” “The Double Effect: Terminal Sedation” by Ann Villet-Lagmarsino

For a good forum of topic discussion click here —– check it out

The Patient Self Determination Act (PSDA)

In order to protect the rights of its citizens, Congress passed the Patient Self-Determination Act in 1991. This law makes it clear that you have the right to make decisions regarding your medical care including the right to accept or refuse treatment and the right to make an advance directive. The law also requires health care facilities/agencies to discuss advance health care directives with you as you enter their system.

MOST hospitals, nursing homes, home health agencies, and HMO’s are required by Federal Law to provide you with information regarding Advance Health Care Directive.

The Patient Self-Determination Act (PSDA) simply requires that most health care institutions (but not individual doctors) do the following:

(1) Give you at the time of admission a WRITTEN summary of:

• Your health care decision-making rights (Each state has developed such a summary for hospitals, nursing homes, and home health agencies to use);
• the facility’s policies with respect to recognizing advance directives.

(2) Ask you if you have an advance directive, and document that fact in your medical record if you do. (It is up to you to make sure they get a copy of it).

(3) Educate their staff and community about advance directives.

(4) Never discriminate against patients based on whether or not they have an advance directive. Thus, it is against the law for them to require either that you have or not have an advance directive.

Information retrieved from:

http://www.legalhelpmate.com/health-care-directive-patient-act.aspx

Minnesota Palliative Care

The Minnesota Palliative Care Partnership was originally organized in 1999 as the Minnesota Partnership to Improve End of Life Care. It was founded by Allina Health Systems, Blue Cross Blue Shield of Minnesota, Fairview Health Services, and HealthPartners, all of whom continue to be the partners today. The Minnesota Partnership to Improve End of Life Care was originally under the financial management of the Metro Area Agency on Aging.

In its early days, the Partnership received a significant national grant from the Robert Wood Johnson Foundation to establish the Minnesota Commission on End of Life Care. The Commission was a joint effort of the Partnership and the Minnesota State Department of Health. It was co-chaired by Barry Baines, M.D., then of HealthPartners, and Jan Malcolm, then State Commissioner of Health. It included a diverse group of people from service provider organizations, academia, rural health experts, bioethics, several professional organizations, the clergy, and several minority health groups.

The Minnesota Commission on End of Life examined information and statistics from multiple sources, conducted numerous interviews, particularly focused on minorities and immigrants, and held four community round table discussions outside the Twin Cities. It met for nearly two years, and issued its recommendations in a Final Report in early 2002.

The Commission’s Final Report, and its recommendations for improving the status and standards for end of life care in the state, have become the basis for subsequent action taken by numerous parties. For example, Hospice Minnesota has since offered extensive training for hospice staff and leadership in the cultural concerns surrounding death and dying in various minority communities. The Commission established Five Guiding Principles for compassionate end of life care. These principles have been widely disseminated to Minnesota health care providers and are posted and followed in numerous health care settings.

One of the Partnership’s priorities in 2003 and continuing is to explore the possibilities of restructuring health insurance to provide funding for palliative care at the end of life and earlier for those people who do not qualify for hospice or home care benefits. Palliative care is a broad term applying to care aimed at easing suffering of all types rather than at curing disease. It uses a bio/psycho/social/spiritual model of care and offers services in all those areas, not only to a patient, but also to his or her family or other caregivers. Hospice uses the same philosophy but is only available to people with a prognosis of six months or fewer to live. Home care is only available to adults who are completely, or nearly completely, homebound and to certain children who suffer from advanced diseases. It does not always include all the elements of palliative care. Many other people, not homebound, and their families, are suffering greatly in earlier stages of advanced, life-limiting illness. This latter group is who could benefit greatly from expanded palliative care.

In the fall of 2003, the Partnership published a white paper on palliative care and the case for including expanded palliative care in the menu of health benefits offered by employers. In January 2004, Allina Health Services, a Minnesota-based self-insured employer who is a member of the Partnership, began offering a palliative care benefit to their own employees and their dependents. On June 1, 2004, a second Twin Cities employer, a large hospital, began offering a very similar employee benefit. Two of the other Partnership partners are considering or planning to do the same.

In February 2004, the Partnership’s Board voted to change the name of the organization to the Minnesota Palliative Care Partnership. This change recognized the growing importance the Partnership places on state of the art palliative care, not just at the end of life, but throughout the course of a serious chronic illness.

The Partnership continues to work in several areas aimed at expanding access to excellent palliative care for any who may need it.

The Minnesota Commission on End of Life Care was created because significant gaps exist for people who are facing the end of life. The Commission identified and prioritized the issues that cause the most significant barriers to accessing the best care. After analyzing interviews conducted by staff, data about the number of Minnesotans who die and the particulars of their deaths, and the composition of the health care system, the Commission arrived at recommendations for improving end of life  care. The remainder of this document is a detailed listing of  these recommendations and strategies for their implementation.

Here’s some links to more in-depth information on the Commission finding and Minnesota statistics:

End-of-Life Care in Minnesota, Death Statistics and background

So what is happening in the U.S. concerning political movements and legislation?

Montana

On December 5, 2008, state District Court judge Dorothy McCarter ruled in favor of a terminally ill Billings resident who had filed a lawsuit with the assistance of Compassion & Choices, a patient rights group. The ruling states that competent, terminally ill patients have the right to self-administer lethal doses of medication as prescribed by a physician. Physicians who prescribe such medications will not face legal punishment. On September 2, 2009, the Montana Supreme Court heard arguments in Baxter v. Montana.

Oregon
Ballot Measure 16 in 1994 established the Oregon Death with Dignity Act , which legalizes physician-assisted dying with certain restrictions, making Oregon the first U.S. state and one of the first jurisdictions in the world to officially do so. The measure was approved in the 8 November 1994 general election in a tight race with the final tally showing 627,980 votes (51.3%) in favor, and 596,018 votes (48.7%) against. The law survived an attempted repeal in 1997, which was defeated at the ballot by a 60% vote. In 2005, after several attempts by lawmakers at both the state and federal level to overturn the Oregon law, the Supreme Court of the United States ruled 6-3 to uphold the law after hearing arguments in the case of Gonzales v. Oregon .

Texas
In 1999, the state of Texas passed the Texas Futile Care Law. Under the law, in some situations, Texas hospitals and physicians have the right to withdraw life support measures, such as mechanical respiration, from terminally ill patients when such treatment is considered to be both futile and inappropriate. In 2005, a six-month-old infant , Sun Hudson , with a uniformly fatal disease thanatophoric dysplasia , was the first patient in which “a United States court has allowed life-sustaining treatment to be withdrawn from a pediatric patient over the objections of the child’s parent.”

Washington
WASHINGTON DEATH WITH DIGNITY ACT
In 2008, assisted suicide in the state of Washington was made legal by Initiative 1000.
Initiative 1000 (I-1000) of 2008 established the U.S. state of Washington ‘s Death with Dignity Act 70.245, which legalizes physician-assisted dying with certain restrictions. Passage of this initiative made Washington the second U.S. state to permit some terminally ill patients to determine the time of their own death. The effort was headed by former Governor Booth Gardner.

The measure was approved in the November 4, 2008 general election. 1,715,219 votes (57.82%) were cast in favor, 1,251,255 votes (42.18%) against. There were 2,966,474 votes total. 30 of the state’s 39 counties voted in favor of the initiative.

In 1991, the similar initiative 119 was rejected by Washington voters by a margin of 54 percent to 46 percent. I-119 would have allowed doctors to prescribe a lethal dosage of medication, and also to administer it if the terminally ill patient could not self-administer. Unlike that initiative, I-1000 requires the patient to ingest the medication unassisted.

The initiative is based on Oregon Measure 16, which Oregon voters passed in 1994. Oregon is the only state to have enacted similar legislation, and overwhelmingly re-approve it after the Oregon State Legislature referred a repeal of it to voters in 1997.

Special provisions of Initiative 1000
The official ballot summary for the measure, slightly amended following a February 2008 court challenge, is, “This measure would permit terminally ill, adult Washington residents medically predicted to die within six months to request and self-administer lethal medication prescribed by a physician. The measure requires two oral and one written request, two physicians to diagnose the patient and determine the patient is competent, a waiting period, and physician verification of an informed patient decision. Physicians, patients and others acting in good faith compliance would have criminal and civil immunity.”

Provisions in the law include:

• The patient must be an adult (18 or over) resident of the state of Washington
• The patient must be mentally competent, verified by two physicians (or referred to a mental health evaluation)
• The patient must be terminally ill with less than 6 months to live, verified by two physicians.
• The patient must make voluntary requests, without coercion, verified by two physicians
• The patient must be informed of all other options including palliative and hospice care
• There is a 15 day waiting period between the first oral request and a written request
• There is a 48 hour waiting period between the written request and the writing of the prescription
• The written request must be signed by two independent witnesses, at least one of whom is not related to the patient or employed by the health care facility
• The patient is encouraged to discuss with family (not required because of confidentiality laws)
• The patient may change their mind at any time and rescind the request
  

Support of Initiative 1000
The campaign was run by a coalition that includes former Washington governor, Booth Gardner and aid-in-dying advocates from Oregon, the Death with Dignity National Center, Compassion & Choices (national) , Compassion & Choices of Washington, Compassion & Choices of Oregon. The name of the official political advocacy group working on the campaign was changed from “It’s My Decision” to “YES on 1000”.

State Senator Darlene Fairley, who chairs the Death with Dignity Disabilities Caucus, said that “as a matter of personal control and autonomy, it makes sense to let patients themselves decide what kind of medical care they want to receive and how long they want to suffer with a terminal illness.”

State Representative Jamie Pedersen, chair of LGBT for 1000, said, “people facing terminal illnesses gain peace of mind from knowing that their end-of-life choices will be respected. Everyone deserves that respect and can appreciate its importance.” Organizations that supported I-1000 include the American Medical Student Association, the American Medical Women’s Association, the Lifelong AIDS Association, the ACLU , the National Women’s Law Center, the Washington Chapter of the National Association of Social Workers, and the Washington State Public Health Association.

The Washington State Psychology Association was neutral on I-1000, but found that “patients choose aid in dying because of a desire for autonomy and the wish to avoid loss of dignity and control, not because of a poor mental state, lack of resources or social support,” and “the law has had a positive effect in terms of significant improvements in palliative care.”

The Newcastle News endorsed the measure in a Oct. 7, 2008, editorial. “Some opponents of I-1000 will refer to the life-death option as assisted suicide, but this has no resemblance to suicide. It is a humane end to a life that is already ending,” the editorial said.

Opposition of Initiative 1000
The Coalition Against Assisted Suicide opposed the measure. It included doctors and nurses, disability rights advocates and organizations, hospice workers, minorities, right-to-life organizations, Christian organizations, the Catholic Church, and politicians from both sides of the aisle. A more comprehensive look at the opposition to I-1000 can be found at the Coalition’s website.

The organization held that the danger of making doctors the agents of a patient’s death far outweighed any advantages to assisted suicide, or safeguards in the initiative’s text. They felt that legalization of assisted suicide would put pressure on minorities, the disabled, and the poor.

Actor Martin Sheen appeared in television ads opposing Initiative 1000. There has been some debate over one of Sheen’s statements: persons with depression can be given a lethal dose without prior professional assessment. According to the Washington Death with Dignity act, “Medication to end a patient’s life in a humane and dignified manner shall not be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment.” This issue has been explored in the field of medical ethics.

Not Dead Yet, a disabilities advocacy group which joined with the Coalition Against Assisted Suicide, objected to the measure, arguing that it discriminates against and targets the disabled. They believe that disabled people who are worried they will become a burden to their families need help and pain relief for their conditions, not encouragement to die.

Unsuccessful Initiatives
Attempts to legalize euthanasia and assisted suicide resulted in ballot initiatives and legislation bills within the United States in the last 20 years. For example, Washington voters saw Ballot Initiative 119 in 1991, California placed Proposition 161 on the ballot in 1992, Oregon passed the Death with Dignity Act in 1994, and Michigan included Proposal B in their ballot in 1998. Despite the earlier failure, in November 2008 euthanasia was approved in Washington by Initiative 1000 .

The California Compassionate Choices Act was introduced in 2005, patterned after Oregon’s Death with Dignity Act. After being defeated in 2006, it was introduced as AB 374 in 2007.

Euthanasia–what is it?

Euthanasia (from the Greek  εὐθανασία meaning “good death”: εὖ, eu (well or good) + θάνατος, thanatos (death)) refers to the practice of ending a life in a manner which relieves pain and suffering.

Etymology
Like other terms borrowed from history, the “euthanasia” has had different meanings depending on usage. The first apparent usage of the term “euthanasia” belongs to the historian Suetonius who described how the Emperor Augustus, “dying quickly and without suffering in the arms of his wife, Livia, experienced the “euthanasia” he had wished for.” The word “euthanasia” was first used in a medical context by Francis Bacon in the 17th century, to refer to an easy, painless, happy death, during which it was a “physician’s responsibility to alleviate the “physical sufferings” of the body.” Bacon referred to an “outward euthanasia” —the term “outward” he used to distinguish from a spiritual concept —the euthanasia “which regards the preparation of the soul.”

In current parlance it has come to mean different but related things depending on philosophy and political persuasion: Opponents to euthanasia and assisted suicide , refer to an “active causation of a patient’s death by a physician”.Proponents instead refer to palliative care and easing of suffering.

Classification of Euthanasia
Euthanasia may be classified according to whether a person gives informed consent into three types: voluntary, non-voluntary and involuntary.

There is a debate within the medical and bioethics literature about whether or not the non-voluntary (and by extension, involuntary) killing of patients can be regarded as euthanasia, irrespective of intent or the patient’s circumstances. In the definitions offered by Beauchamp & Davidson and, later, by Wreen, consent on the part of the patient was not considered to be one of their criteria. However, others see consent as essential. For example, in a discussion of euthanasia presented in 2003 by the European Association of Palliative Care (EPAC) Ethics Task Force, the authors offered the unambiguous statement:

“Medicalized killing of a person without the person’s consent, whether nonvoluntary (where the person in unable to consent) or involuntary (against the person’s will) is not euthanasia: it is murder. Hence, euthanasia can be voluntary only.”

Voluntary Euthanasia
Euthanasia conducted with the consent of the patient is termed voluntary euthanasia. Voluntary euthanasia is legal in Belgium, Luxembourg, the Netherlands, Switzerland, and the U.S. states of Oregon and Washington. When the patient brings about his or her own death with the assistance of a physician, the term assisted suicide is often used instead.

Involuntary Euthanasia
Euthanasia conducted against the will of the patient is termed involuntary euthanasia. Involuntary euthanasia is widely opposed and is regarded as a crime in legal jurisdictions, and is sometimes used as a reason for not changing laws relating to other forms of euthanasia. Historically, involuntary euthanasia has received some support from parts of the pro-euthanasia movement. In 1937 a bill that included provisions for involuntary euthanasia was proposed in Nebraska , although it never went before the state legislature; and in 1943 a committee was formed by the Euthanasia Society of America that was to draft a bill that incorporated involuntary euthanasia for “idiots, imbeciles, and congenital monstrosities”.

[Read about non-voluntary and involuntary euthanasia. in my next post]