Academic literature on the topic 'Urbana (Ill.). Free Public Library'

Purpose – This paper aims to describe the state of the art of the Italian Archivio Licenze Periodici Elettronici (ALPE) project which aims to improve the understanding of the issues raised by licence agreements of electronic resources in the Inter-Library Loan Service and to support librarians in the implementation of the right policies. Design/methodology/approach – ALPE – (E-Journals Licenses Archive) is a national archive of interlibrary loan (ILL) clauses, extracted from standard and negotiated licences, to manage, to publicly share and to check the permitted uses of e-resources for ILL and document delivery. Findings – The ALPE archive facilitates public and free access to a remarkable amount of information and data about ILL conditions granted by the most important commercial and academic publishers, and responds to the practical problems of managing and understanding ILL clauses in e-licences. Originality/value – The solutions adopted by ALPE effectively solve many of the problems reported in the literature. These should help ILL librarians in dealing with the problems associated with ILL and licensing.

Abstract The article presents the library system of the University of Illinois in Urbana-Champaign, structure and functioning of the library system of Illinois, education and training of library staff and academic librarians` status and promotion. The author points out also some current dilemmas of public and school libraries in Illinois, which are connected with the problem of intellectual freedom and free access to information, as that of internet filtering, free access to information for minors, library acquisition policy, library buildings and premises, etc.

BackgroundWelfare legal problems and inadequate access to support services follow both the socioeconomic and the health inequalities gradients. Health Justice Partnership (HJP) is an international practitioner-led movement which brings together legal and healthcare professionals to address the root causes of ill health from negative social determinants. The aim of this paper was to identify the current evidence base for the cost-effectiveness of HJP or comparable welfare advice services.MethodsA rapid review format was used, with a literature search of PubMed, CINAHL, ASSIA, PsycINFO, Medline, Cochrane Library, Global Health and Web of Science identifying 496 articles. After removal of duplicates, 176 papers were screened on titles and abstracts, and 20 papers met the eligibility criteria. Following a full-text screening, a further 14 papers were excluded due to lack of economic evaluations. Excluded papers' reference lists were scanned, with a further 3 further papers identified which met the inclusion criteria. A final pool of nine studies were included in this review.ResultsStudies focused on the financial benefit to service users, with only three studies reporting on cost effectiveness of the interventions. Only one study reported on the economic impact of change of health in service users and one study reported on changes in health service use.ConclusionThis review highlights the current evidence gap in evaluating the cost-effectiveness of adequate access to free legal welfare advice and representation. We propose that an interdisciplinary research agenda between health economics and legal-health services is required to address this research gap.

Abstract Background: Health services utilization, as one of the mechanisms of the health system, guarantees a healthy life and improves well-being for everyone. Aims: The aim of this study was to identify factors affecting the use of outpatient health services among women. Methods/designs: This scoping review examined the studies related to outpatient health services utilization (OHSU) and its determinants among women. This review was conducted on English language studies published between 2010 and 2023 (All searches were conducted on 20 January 2023). Studies available in databases such as Web of Science, MEDLINE (PubMed), Scopus, Wiley library, Proquest, and Google Scholar were searched manually. Selected keywords and their equivalents were used to search for related articles in each database. Results: A total of 18 795 articles were identified, of which 37 met the inclusion criteria. Findings showed that age, marital status, level of education, employment status, income level, socioeconomic status, rape experience, health insurance, health status, ethnicity, living in rural areas, quality of services, area of residence, having a purpose in life and access to health services affect OHSU among women. Conclusions: The results of the present review showed that in order to achieve the universal goals of health services coverage and health service utilization, it is necessary for countries to provide insurance coverage to the maximum number of people. Also, policies should change in favor of the elderly, poor and low-income, low-educated, rural, ethnic minority, and chronically ill women and provide them with free preventive health services.

Oppel, Kenneth. This Dark Endeavour: The Apprenticeship of Victor Frankenstein. Toronto: Harper Collins, 2011. Print. Victor has always felt less than worthy compared to his twin brother, Konrad, who is the better swordsman, the more gracious gentleman, and the beloved of their cousin Elizabeth, whom they both love dearly. Yet when Konrad falls mysteriously and deathly ill, Victor’s love for his brother encourages him to follow a dangerous quest. Victor is a passionate, if somewhat arrogant, protagonist, who is at times unlikeable, yet strangely alluring. Victor has recently stumbled upon the hidden Dark Library in the family’s chateau, a library filled with ancient scientific works by such legendary alchemists as Paracelsus and Agrippa. In direct violation of his father’s orders, Victor wishes to create the Elixir of Life that he believes will save his brother. He, Elizabeth, and their family friend, Henry, seek the help of local alchemist and outcast, Julius Polidori, whose apothecary shop is coincidentally located in Wollstonecraft Alley. Polidori promises to translate the ancient texts and instruct Victor on how to collect the three necessary ingredients for the elixir. The recovery of each of the key substances frequently puts the characters in life-threatening situations while testing their bravery and dedication to their quest. This dark tale ends in such a foreboding way, promising future adventures for Victor. This is an absorbing gothic tale that serves as a prequel to Mary Shelley’s Frankenstein. Aimed at teens, it will hopefully serve as a unique way to get young adults interested in both classic literature and the history of science and magic. This book will likely appeal to those who enjoyed the later darker novels in the Harry Potter series, as it too explores the interconnections between faith, science, and magic. Paracelsus and Agrippa were mentioned in Harry Potter and the Philosopher’s Stone, in which alchemy was also a prevalent theme. Readers will find the adventure captivating, and may want to watch for the movie version, which is expected to be released in 2013. Highly Recommended: 4 out of 4 starsReviewer: Trish ChatterleyTrish is a Public Services Librarian for the John W. Scott Health Sciences Library at the University of Alberta. In her free time she enjoys dancing, gardening, and reading books of all types.

AbstractIn the realm of acute respiratory infections, coronavirus disease-19 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a global public health challenge. The application of corticosteroids (CSs) in COVID-19 remains a contentious topic among researchers. Accordingly, our team performed a comprehensive meta-analysis of randomized controlled trials (RCTs) to meticulously evaluate the safety and efficacy of CSs in hospitalized COVID-19 patients. To explore efficacy of CSs in the treatment of COVID-19 patients, we meticulously screened RCTs across key databases, including PubMed, Web of Science, Embase, Cochrane Library, ClinicalTrials.gov, as well as China's CNKI and Wanfang Data. We focused on assessing the 28 days mortality rates. We evaluated the data heterogeneity using the Chi-square test and I2 values, setting significance at 0.1 and 50%. Data from 21 RCTs involving 5721 participants were analyzed. The analysis did not demonstrate a significant association between CSs intervention and the 28 days mortality risk in hospitalized COVID-19 patients (relative risk [RR] = 0.93; 95% confidence interval [95% CI]: 0.84–1.03; P = 0.15). However, subgroup analysis revealed a significant reduction in 28 days mortality among patients with moderate-to-severe COVID-19 (RR at 0.85; 95% CI: 0.76–0.95; P = 0.004). Specifically, short-term CS administration (≤ 3 days) was associated with a substantial improvement in clinical outcomes (RR = 0.24; 95% CI: 0.09–0.63; P = 0.004), as was longer-term use (≥ 8 days) (RR = 0.88; 95% CI: 0.77–0.99; P = 0.04). Additionally, in patients with moderate-to-severe COVID-19, the administration of dexamethasone increased the number of 28 days ventilator-free days (Mean Difference = 1.92; 95% CI: 0.44–3.40; P = 0.01). Methylprednisolone also demonstrated significant benefits in improving clinical outcomes (RR = 0.24; 95% CI: 0.09–0.63; P = 0.004). Our meta-analysis demonstrated that although there is no significant difference in 28 days mortality rates among hospitalized COVID-19 patients, the use of CSs may be beneficial in improving clinical outcomes in moderate or severe COVID-19 patients. There was no significant increase in the occurrence of adverse events associated with the use of CSs. Our meta-analysis provides evidence that while CSs may not be suitable for all COVID-19 patients, they could be effective and safe in severely ill COVID-19 patients. Consequently, it is recommended to administer CSs for personalized treatments in COVID-19 cases to improve the clinical outcomes while minimizing adverse events.

On 23 August 2005, John Howard, then Prime Minister, called together Muslim ‘representatives’ from around the nation for a Muslim Summit in response to the London bombings in July of that year. One of the outcomes of the two hour summit was a Statement of Principles committing Muslim communities in Australia to resist radicalisation and pursue a ‘moderate’ Islam. Since then the ill-defined term ‘moderate Muslim’ has been used in both the political and media discourse to refer to a preferred form of Islamic practice that does not challenge the hegemony of the nation state and that is coherent with the principles of secularism. Akbarzadeh and Smith conclude that the terms ‘moderate’ and ‘mainstream’ are used to describe Muslims whom Australians should not fear in contrast to ‘extremists’. Ironically, the policy direction towards regulating the practice of Islam in Australia in favour of a state defined ‘moderate’ Islam signals an attempt by the state to mediate the practice of religion, undermining the ethos of secularism as it is expressed in the Australian Constitution. It also – arguably – impacts upon the citizenship rights of Australian Muslims in so far as citizenship presents not just as a formal set of rights accorded to an individual but also to democratic participation: the ability of citizens to enjoy those rights at a substantive level. Based on the findings of research into how Australian Muslims and members of the broader community are responding to the political and media discourses on terrorism, this article examines the impact of these discourses on how Muslims are practicing citizenship and re-defining an Australian Muslim identity. Free Speech Free speech has been a hallmark of liberal democracies ever since its defence became part of the First Amendment to the United States Constitution. The Australian Constitution does not expressly contain a provision for free speech. The right to free speech in Australia is implied in Australia’s ratification of the United Nations Universal Declaration of Human Rights (UDHR), article 19 of which affirms: Article 19. Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers. The ultimate recent endorsement of free speech rights, arguably associated with the radical free speech ‘open platform’ movement of the 1960s at the University of California Berkeley, constructs free speech as essential to human and civil liberties. Its approach has been expressed in terms such as: “I reject and detest XYZ views but will defend to the utmost a person’s right to express them”. An active defence of free speech is based on the observation that, unless held to account, “[Authorities] would grant free speech to those with whom they agree, but not to minorities whom they consider unorthodox or threatening” (“Online Archives of California”). Such minorities, differing from the majority view, do so as a right accorded to citizens. In very challenging circumstances – such as opposing the Cold War operations of the US Senate Anti-American Activities Committee – the free speech movement has been celebrated as holding fast (or embodying a ‘return’) to the true meaning of the American First Amendment. It was in public statements of unpopular and minority views, which opposed those of the majority, that the right to free speech could most non-controvertibly be demonstrated. Some have argued that such rights should be balanced by anti-vilification legislation, by prohibitions upon incitement to violence, and by considerations as to whether the organisation defended by the speaker was banned. In the latter case, there can be problems with excluding the defence of banned organisations from legitimate debate. In the 1970s and 1980s, for example, Sinn Fein was denounced in the UK as the ‘political wing of the IRA’ (the IRA being a banned organisation) and denied a speaking position in many forums, yet has proved to be an important party in the eventual reconciliation of the Northern Ireland divide. In effect, the banning of an organisation is a political act and such acts should best be interrogated through free speech and democratic debate. Arguably, such disputation is a responsibility of an involved citizenry. In general, liberal democracies such as Australia do not hesitate to claim that citizens have a right to free speech and that this is a right worth defending. There is a legitimate expectation by Australians of their rights as citizens to freedom of expression. For some Australian Muslims, however, the appeal to free speech seems a hollow one. Muslim citizens run the risk of being constructed as ‘un-Australian’ when they articulate their concerns or opinions. Calls by some Muslim leaders not to reprint the Danish cartoons depicting images of the Prophet Mohammed for example, met with a broader community backlash and drew responses that, typically, constructed Muslims as a threat to Australian cultural values of freedom and liberty. These kinds of responses to expressions by Australian Muslims of their deeply held convictions are rarely, if ever, interpreted as attempts to curtail Australian Muslims’ rights to free speech. There is a poor fit between what many Australian Muslims believe and what they feel the current climate in Australia allows them to say in the public domain. Positioned as the potential ‘enemy within’ in the evolving media and political discourse post September 11, they have been allocated restricted speaking positions on many subjects from the role and training of their Imams to the right to request Sharia courts (which could operate in parallel with Australian courts in the same way that Catholic divorce/annulment courts do). These social and political restrictions lead them to question whether Muslims enjoy citizenship rights on an equal footing with Australians from the broader community. The following comment from an Australian woman, an Iraqi refugee, made in a research interview demonstrates this: The media say that if you are Australian it means that you enjoy freedom, you enjoy the rights of citizenship. That is the idea of what it means to be Australian, that you do those things. But if you are a Muslim, you are not Australian. You are a people who are dangerous, a people who are suspicious, a people who do not want democracy—all the characteristics that make up terrorists. So yes, there is a difference, a big difference. And it is a feeling all Muslims have, not just me, whether you are at school, at work, and especially if you wear the hijab. (Translated from Arabic by Anne Aly) At the same time, Australian Muslims observe some members of the broader community making strong assertions about Muslims (often based on misunderstanding or misinformation) with very little in the way of censure or rebuke. For example, again in 2005, Liberal backbenchers Sophie Panopoulos and Bronwyn Bishop made an emotive plea for the banning of headscarves in public schools, drawing explicitly on the historically inherited image of Islam as a violent, backward and oppressive ideology that has no place in Western liberal democracy: I fear a frightening Islamic class emerging, supported by a perverse interpretation of the Koran where disenchantment breeds disengagement, where powerful and subversive orthodoxies are inculcated into passionate and impressionable young Muslims, where the Islamic mosque becomes the breeding ground for violence and rejection of Australian law and ideals, where extremists hijack the Islamic faith with their own prescriptive and unbending version of the Koran and where extremist views are given currency and validity … . Why should one section of the community be stuck in the Dark Ages of compliance cloaked under a veil of some distorted form of religious freedom? (Panopoulos) Several studies attest to the fact that, since the terrorist attacks in the United States in September 2001, Islam, and by association Australian Muslims, have been positioned as other in the political and media discourse (see for example Aly). The construct of Muslims as ‘out of place’ (Saniotis) denies them entry and representation in the public sphere: a key requisite for democratic participation according to Habermas (cited in Haas). This notion of a lack of a context for Muslim citizenship in Australian public spheres arises out of the popular construction of ‘Muslim’ and ‘Australian’ as mutually exclusive modes of being. Denied access to public spaces to partake in democratic dialogue as political citizens, Australian Muslims must pursue alternative communicative spaces. Some respond by limiting their expressions to closed spheres of communication – a kind of enforced silence. Others respond by pursuing alternative media discourses that challenge the dominant stereotypes of Muslims in Western media and reinforce majority-world cultural views. Enforced Silence In closed spheres of discussion, Australian Muslims can openly share their perceptions about terrorism, the government and media. Speaking openly in public however, is not common practice and results in forced silence for fear of reprisal or being branded a terrorist: “if we jump up and go ‘oh how dare you say this, rah, rah’, he’ll be like ‘oh he’s going to go off, he’ll blow something up’”. One research participant recalled that when his work colleagues were discussing the September 11 attacks he decided not to partake in the conversation because it “might be taken against me”. The participant made this decision despite the fact that his colleagues were expressing the opinion that United States foreign policy was the likely cause for the attacks—an opinion with which he agreed. This suggests some support for the theory that the fear of social isolation may make Australian Muslims especially anxious or fearful of expressing opinions about terrorism in public discussions (Noelle-Neumann). However, it also suggests that the fear of social isolation for Muslims is not solely related to the expression of minority opinion, as theorised in Noelle-Neumann’s Spiral of Silence . Given that many members of the wider community shared the theory that the attacks on the Pentagon and the World Trade Centre in 2001 may have been a response to American foreign policy, this may well not be a minority view. Nonetheless, Australian Muslims hesitated to embrace it. Saniotis draws attention to the pressure on Australian Muslims to publicly distance themselves from the terrorist attacks of September 11 and to openly denounce the actions of terrorists. The extent to which Muslims were positioned as a threatening other was contingent on their ability to demonstrate that they too participated in the distal responses to the terrorist attacks—initial pity for the sufferer and eventual marginalisation and rejection of the perceived aggressor. Australian Muslims were obliged to declare their loyalty and commitment to Australia’s ally and, in this way, partake in the nationalistic responses to the threat of terrorism. At the same time however, Australian Muslims were positioned as an imagined enemy and a threat to national identity. Australian Muslims were therefore placed in a paradoxical bind- as Australians they were expected to respond as the victims of fear; as Muslims they were positioned as the objects of fear. Even in discussions where their opinions are congruent with the dominant opinion being expressed, Australian Muslims describe themselves as feeling apprehensive or anxious about expressing their opinions because of how these “might be taken”. Pursuing alternative discourses The overriding message from the research project’s Muslim participants was that the media, as a powerful purveyor of public opinion, had inculcated a perception of Muslims as a risk to Australia and Australians: an ‘enemy within’; the potential ‘home grown terrorist’. The daily experience of visibly-different Australian Muslims, however, is that they are more fearing than fear-inspiring. The Aly and Balnaves fear scale indicates that Australian Muslims have twice as many fear indicators as non-Muslims Australians. Disengagement from Western media and media that is seen to be influenced or controlled by the West is widespread among Australian Muslims who increasingly argue that the media institutions are motivated by an agenda that includes profit and the perpetuation of a negative stereotype of Muslims both in Australia and around the globe, particularly in relation to Middle Eastern affairs. The negative stereotypes of Muslims in the Australian media have inculcated a sense of victimhood which Muslims in Australia have used as the basis for a reconstruction of their identity and the creation of alternative narratives of belonging (Aly). Central to the notion of identity among Australian Muslims is a sense of having their citizenship rights curtailed by virtue of their faith: of being included in a general Western dismissal of Muslims’ rights and experiences. As one interviewee said: If you look at the Channel Al Jazeera for example, it’s a channel but they aren’t making up stories, they are taping videos in Iraqi, Palestine and other Muslim countries, and they just show it to people, that’s all they do. And then George Bush, you know, we hear on the news that George Bush was discussing with Tony Blair that he was thinking to bomb Al Jazeera so why would these people have their right to freedom and we don’t? So that’s why I think the people who are in power, they have the control over the media, and it’s a big political game. Because if it wasn’t then George Bush, he’s the symbol of politics, why would he want to bomb Al Jazeera for example? Amidst leaks and rumours (Timms) that the 2003 US bombing of Al Jazeera was a deliberate attack upon one of the few elements of the public sphere in which some Western-nationality Muslims have confidence, many elements of the mainstream Western media rose to Al Jazeera’s defence. For example, using an appeal to the right of citizens to engage in and consume free speech, the editors of influential US paper The Nation commented that: If the classified memo detailing President Bush’s alleged proposal to bomb the headquarters of Al Jazeera is provided to The Nation, we will publish the relevant sections. Why is it so vital that this information be made available to the American people? Because if a President who claims to be using the US military to liberate countries in order to spread freedom then conspires to destroy media that fail to echo his sentiments, he does not merely disgrace his office and soil the reputation of his country. He attacks a fundamental principle, freedom of the press—particularly a dissenting and disagreeable press—upon which that country was founded. (cited in Scahill) For other Australian Muslims, it is the fact that some media organisations have been listed as banned by the US that gives them their ultimate credibility. This is the case with Al Manar, for example. Feeling that they are denied access to public spaces to partake in democratic dialogue as equal political citizens, Australian Muslims are pursuing alternative communicative spaces that support and reinforce their own cultural worldviews. The act of engaging with marginalised and alternative communicative spaces constitutes what Clifford terms ‘collective practices of displaced dwelling’. It is through these practices of displaced dwelling that Australian Muslims essentialise their diasporic identity and negotiate new identities based on common perceptions of injustice against Muslims. But you look at Al Jazeera they talk in the same tongue as the Western media in our language. And then you look again at something like Al Manar who talks of their own tongue. They do not use the other media’s ideas. They have been attacked by the Australians, been attacked by the Israelis and they have their own opinion. This statement came from an Australian Muslim of Jordanian background in her late forties. It reflects a growing trend towards engaging with media messages that coincide with and reinforce a sense of injustice. The Al Manar television station to which this participant refers is a Lebanese based station run by the militant Hezbollah movement and accessible to Australians via satellite. Much like Al Jazeera, Al Manar broadcasts images of Iraqi and Palestinian suffering and, in the recent war between Israel and Hezbollah, graphic images of Lebanese casualties of Israeli air strikes. Unlike the Al Jazeera broadcasts, these images are formatted into video clips accompanied by music and lyrics such as “we do not fear America”. Despite political pressure including a decision by the US to list Al Manar as a terrorist organisation in December 2004, just one week after a French ban on the station because its programming had “a militant perspective with anti-Semitic connotations” (Jorisch), Al Manar continued to broadcast videos depicting the US as the “mother of terrorism”. In one particularly graphic sequence, the Statue of Liberty rises from the depths of the sea, wielding a knife in place of the torch and dripping in blood, her face altered to resemble a skull. As she rises out of the sea accompanied by music resembling a funeral march the following words in Arabic are emblazoned across the screen: On the dead bodies of millions of native Americans And through the enslavement of tens of millions Africans The US rose It pried into the affairs of most countries in the world After an extensive list of countries impacted by US foreign policy including China, Japan, Congo, Vietnam, Peru, Laos, Libya and Guatamala, the video comes to a gruelling halt with the words ‘America owes blood to all of humanity’. Another video juxtaposes images of Bush with Hitler with the caption ‘History repeats itself’. One website run by the Coalition against Media Terrorism refers to Al Manar as ‘the beacon of hatred’ and applauds the decisions by the French and US governments to ban the station. Al Manar defended itself against the bans stating on its website that they are attempts “to terrorise and silence thoughts that are not in line with the US and Israeli policies.” The station claims that it continues on its mission “to carry the message of defending our peoples’ rights, holy places and just causes…within internationally agreed professional laws and standards”. The particular brand of propaganda employed by Al Manar is gaining popularity among some Muslims in Australia largely because it affirms their own views and opinions and offers them opportunities to engage in an alternative public space in which Muslims are positioned as the victims and not the aggressors. Renegotiating an ‘Othered’ Identity The negative portrayal of Muslims as ‘other’ in the Australian media and in political discourse has resulted in Australian Muslims constructing alternative identities based on a common perception of injustice. Particularly since the terrorist attacks on the World Trade Centre in September 2001 and the ensuing “war on terror”, the ethnic divisions within the Muslim diaspora are becoming less significant as Australian Muslims reconstruct their identity based on a notion of supporting each other in the face of a global alliance against Islam. Religious identity is increasingly becoming the identity of choice for Muslims in Australia. This causes problems, however, since religious identity has no place in the liberal democratic model, which espouses secularism. This is particularly the case where that religion is sometimes constructed as being at odds with the principles and values of liberal democracy; namely tolerance and adherence to the rule of law. This problematic creates a context in which Muslim Australians are not only denied their heterogeneity in the media and political discourse but are dealt with through an understanding of Islam that is constructed on the basis of a cultural and ideological clash between Islam and the West. Religion has become the sole and only characteristic by which Muslims are recognised, denying them political citizenship and access to the public spaces of citizenship. Such ‘essentialising practices’ as eliding considerable diversity into a single descriptor serves to reinforce and consolidate diasporic identity among Muslims in Australia, but does little to promote and assist participatory citizenship or to equip Muslims with the tools necessary to access the public sphere as political citizens of the secular state. In such circumstances, the moderate Muslim may be not so much a ‘preferred’ citizen as one whose rights has been constrained. Acknowledgment This paper is based on the findings of an Australian Research Council Discovery Project, 2005-7, involving 10 focus groups and 60 in-depth interviews. The authors wish to acknowledge the participation and contributions of WA community members. References Akbarzadeh, Shahram, and Bianca Smith. The Representation of Islam and Muslims in the Media (The Age and Herald Sun Newspapers). Melbourne: Monash University, 2005. Aly, Anne, and Mark Balnaves. ”‘They Want Us to Be Afraid’: Developing Metrics of the Fear of Terrorism.” International Journal of Diversity in Organisations, Communities and Nations 6 (2007): 113-122. Aly, Anne. “Australian Muslim Responses to the Discourse on Terrorism in the Australian Popular Media.” Australian Journal of Social Issues 42.1 (2007): 27-40. Clifford, James. Routes: Travel and Translation in the Late Twentieth Century. London: Harvard UP, 1997. Haas, Tanni. “The Public Sphere as a Sphere of Publics: Rethinking Habermas’s Theory of the Public Sphere.” Journal of Communication 54.1 (2004): 178- 84. Jorisch, Avi. J. “Al-Manar and the War in Iraq.” Middle East Intelligence Bulletin 5.2 (2003). Noelle-Neumann, Elisabeth. “The Spiral of Silence: A Theory of Public Opinion.” Journal of Communication 24.2 (1974): 43-52. “Online Archives of California”. California Digital Library. n.d. Feb. 2008 < http://content.cdlib.org/ark:/13030/kt1199n498/?&query= %22open%20platform%22&brand=oac&hit.rank=1 >. Panopoulos, Sophie. Parliamentary debate, 5 Sep. 2005. Feb. 2008 < http://www.aph.gov.au.hansard >. Saniotis, Arthur. “Embodying Ambivalence: Muslim Australians as ‘Other’.” Journal of Australian Studies 82 (2004): 49-58. Scahill, Jeremy. “The War on Al-Jazeera (Comment)”. 2005. The Nation. Feb. 2008 < http://www.thenation.com/doc/20051219/scahill >. Timms, Dominic. “Al-Jazeera Seeks Answers over Bombing Memo”. 2005. Media Guardian. Feb. 2008 < http://www.guardian.co.uk/media/2005/nov/23/iraq.iraqandthemedia >.

On 23 August 2005, John Howard, then Prime Minister, called together Muslim ‘representatives’ from around the nation for a Muslim Summit in response to the London bombings in July of that year. One of the outcomes of the two hour summit was a Statement of Principles committing Muslim communities in Australia to resist radicalisation and pursue a ‘moderate’ Islam. Since then the ill-defined term ‘moderate Muslim’ has been used in both the political and media discourse to refer to a preferred form of Islamic practice that does not challenge the hegemony of the nation state and that is coherent with the principles of secularism. Akbarzadeh and Smith conclude that the terms ‘moderate’ and ‘mainstream’ are used to describe Muslims whom Australians should not fear in contrast to ‘extremists’. Ironically, the policy direction towards regulating the practice of Islam in Australia in favour of a state defined ‘moderate’ Islam signals an attempt by the state to mediate the practice of religion, undermining the ethos of secularism as it is expressed in the Australian Constitution. It also – arguably – impacts upon the citizenship rights of Australian Muslims in so far as citizenship presents not just as a formal set of rights accorded to an individual but also to democratic participation: the ability of citizens to enjoy those rights at a substantive level. Based on the findings of research into how Australian Muslims and members of the broader community are responding to the political and media discourses on terrorism, this article examines the impact of these discourses on how Muslims are practicing citizenship and re-defining an Australian Muslim identity. Free Speech Free speech has been a hallmark of liberal democracies ever since its defence became part of the First Amendment to the United States Constitution. The Australian Constitution does not expressly contain a provision for free speech. The right to free speech in Australia is implied in Australia’s ratification of the United Nations Universal Declaration of Human Rights (UDHR), article 19 of which affirms: Article 19. Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers. The ultimate recent endorsement of free speech rights, arguably associated with the radical free speech ‘open platform’ movement of the 1960s at the University of California Berkeley, constructs free speech as essential to human and civil liberties. Its approach has been expressed in terms such as: “I reject and detest XYZ views but will defend to the utmost a person’s right to express them”. An active defence of free speech is based on the observation that, unless held to account, “[Authorities] would grant free speech to those with whom they agree, but not to minorities whom they consider unorthodox or threatening” (“Online Archives of California”). Such minorities, differing from the majority view, do so as a right accorded to citizens. In very challenging circumstances – such as opposing the Cold War operations of the US Senate Anti-American Activities Committee – the free speech movement has been celebrated as holding fast (or embodying a ‘return’) to the true meaning of the American First Amendment. It was in public statements of unpopular and minority views, which opposed those of the majority, that the right to free speech could most non-controvertibly be demonstrated. Some have argued that such rights should be balanced by anti-vilification legislation, by prohibitions upon incitement to violence, and by considerations as to whether the organisation defended by the speaker was banned. In the latter case, there can be problems with excluding the defence of banned organisations from legitimate debate. In the 1970s and 1980s, for example, Sinn Fein was denounced in the UK as the ‘political wing of the IRA’ (the IRA being a banned organisation) and denied a speaking position in many forums, yet has proved to be an important party in the eventual reconciliation of the Northern Ireland divide. In effect, the banning of an organisation is a political act and such acts should best be interrogated through free speech and democratic debate. Arguably, such disputation is a responsibility of an involved citizenry. In general, liberal democracies such as Australia do not hesitate to claim that citizens have a right to free speech and that this is a right worth defending. There is a legitimate expectation by Australians of their rights as citizens to freedom of expression. For some Australian Muslims, however, the appeal to free speech seems a hollow one. Muslim citizens run the risk of being constructed as ‘un-Australian’ when they articulate their concerns or opinions. Calls by some Muslim leaders not to reprint the Danish cartoons depicting images of the Prophet Mohammed for example, met with a broader community backlash and drew responses that, typically, constructed Muslims as a threat to Australian cultural values of freedom and liberty. These kinds of responses to expressions by Australian Muslims of their deeply held convictions are rarely, if ever, interpreted as attempts to curtail Australian Muslims’ rights to free speech. There is a poor fit between what many Australian Muslims believe and what they feel the current climate in Australia allows them to say in the public domain. Positioned as the potential ‘enemy within’ in the evolving media and political discourse post September 11, they have been allocated restricted speaking positions on many subjects from the role and training of their Imams to the right to request Sharia courts (which could operate in parallel with Australian courts in the same way that Catholic divorce/annulment courts do). These social and political restrictions lead them to question whether Muslims enjoy citizenship rights on an equal footing with Australians from the broader community. The following comment from an Australian woman, an Iraqi refugee, made in a research interview demonstrates this: The media say that if you are Australian it means that you enjoy freedom, you enjoy the rights of citizenship. That is the idea of what it means to be Australian, that you do those things. But if you are a Muslim, you are not Australian. You are a people who are dangerous, a people who are suspicious, a people who do not want democracy—all the characteristics that make up terrorists. So yes, there is a difference, a big difference. And it is a feeling all Muslims have, not just me, whether you are at school, at work, and especially if you wear the hijab. (Translated from Arabic by Anne Aly) At the same time, Australian Muslims observe some members of the broader community making strong assertions about Muslims (often based on misunderstanding or misinformation) with very little in the way of censure or rebuke. For example, again in 2005, Liberal backbenchers Sophie Panopoulos and Bronwyn Bishop made an emotive plea for the banning of headscarves in public schools, drawing explicitly on the historically inherited image of Islam as a violent, backward and oppressive ideology that has no place in Western liberal democracy: I fear a frightening Islamic class emerging, supported by a perverse interpretation of the Koran where disenchantment breeds disengagement, where powerful and subversive orthodoxies are inculcated into passionate and impressionable young Muslims, where the Islamic mosque becomes the breeding ground for violence and rejection of Australian law and ideals, where extremists hijack the Islamic faith with their own prescriptive and unbending version of the Koran and where extremist views are given currency and validity … . Why should one section of the community be stuck in the Dark Ages of compliance cloaked under a veil of some distorted form of religious freedom? (Panopoulos) Several studies attest to the fact that, since the terrorist attacks in the United States in September 2001, Islam, and by association Australian Muslims, have been positioned as other in the political and media discourse (see for example Aly). The construct of Muslims as ‘out of place’ (Saniotis) denies them entry and representation in the public sphere: a key requisite for democratic participation according to Habermas (cited in Haas). This notion of a lack of a context for Muslim citizenship in Australian public spheres arises out of the popular construction of ‘Muslim’ and ‘Australian’ as mutually exclusive modes of being. Denied access to public spaces to partake in democratic dialogue as political citizens, Australian Muslims must pursue alternative communicative spaces. Some respond by limiting their expressions to closed spheres of communication – a kind of enforced silence. Others respond by pursuing alternative media discourses that challenge the dominant stereotypes of Muslims in Western media and reinforce majority-world cultural views. Enforced Silence In closed spheres of discussion, Australian Muslims can openly share their perceptions about terrorism, the government and media. Speaking openly in public however, is not common practice and results in forced silence for fear of reprisal or being branded a terrorist: “if we jump up and go ‘oh how dare you say this, rah, rah’, he’ll be like ‘oh he’s going to go off, he’ll blow something up’”. One research participant recalled that when his work colleagues were discussing the September 11 attacks he decided not to partake in the conversation because it “might be taken against me”. The participant made this decision despite the fact that his colleagues were expressing the opinion that United States foreign policy was the likely cause for the attacks—an opinion with which he agreed. This suggests some support for the theory that the fear of social isolation may make Australian Muslims especially anxious or fearful of expressing opinions about terrorism in public discussions (Noelle-Neumann). However, it also suggests that the fear of social isolation for Muslims is not solely related to the expression of minority opinion, as theorised in Noelle-Neumann’s Spiral of Silence . Given that many members of the wider community shared the theory that the attacks on the Pentagon and the World Trade Centre in 2001 may have been a response to American foreign policy, this may well not be a minority view. Nonetheless, Australian Muslims hesitated to embrace it. Saniotis draws attention to the pressure on Australian Muslims to publicly distance themselves from the terrorist attacks of September 11 and to openly denounce the actions of terrorists. The extent to which Muslims were positioned as a threatening other was contingent on their ability to demonstrate that they too participated in the distal responses to the terrorist attacks—initial pity for the sufferer and eventual marginalisation and rejection of the perceived aggressor. Australian Muslims were obliged to declare their loyalty and commitment to Australia’s ally and, in this way, partake in the nationalistic responses to the threat of terrorism. At the same time however, Australian Muslims were positioned as an imagined enemy and a threat to national identity. Australian Muslims were therefore placed in a paradoxical bind- as Australians they were expected to respond as the victims of fear; as Muslims they were positioned as the objects of fear. Even in discussions where their opinions are congruent with the dominant opinion being expressed, Australian Muslims describe themselves as feeling apprehensive or anxious about expressing their opinions because of how these “might be taken”. Pursuing alternative discourses The overriding message from the research project’s Muslim participants was that the media, as a powerful purveyor of public opinion, had inculcated a perception of Muslims as a risk to Australia and Australians: an ‘enemy within’; the potential ‘home grown terrorist’. The daily experience of visibly-different Australian Muslims, however, is that they are more fearing than fear-inspiring. The Aly and Balnaves fear scale indicates that Australian Muslims have twice as many fear indicators as non-Muslims Australians. Disengagement from Western media and media that is seen to be influenced or controlled by the West is widespread among Australian Muslims who increasingly argue that the media institutions are motivated by an agenda that includes profit and the perpetuation of a negative stereotype of Muslims both in Australia and around the globe, particularly in relation to Middle Eastern affairs. The negative stereotypes of Muslims in the Australian media have inculcated a sense of victimhood which Muslims in Australia have used as the basis for a reconstruction of their identity and the creation of alternative narratives of belonging (Aly). Central to the notion of identity among Australian Muslims is a sense of having their citizenship rights curtailed by virtue of their faith: of being included in a general Western dismissal of Muslims’ rights and experiences. As one interviewee said: If you look at the Channel Al Jazeera for example, it’s a channel but they aren’t making up stories, they are taping videos in Iraqi, Palestine and other Muslim countries, and they just show it to people, that’s all they do. And then George Bush, you know, we hear on the news that George Bush was discussing with Tony Blair that he was thinking to bomb Al Jazeera so why would these people have their right to freedom and we don’t? So that’s why I think the people who are in power, they have the control over the media, and it’s a big political game. Because if it wasn’t then George Bush, he’s the symbol of politics, why would he want to bomb Al Jazeera for example? Amidst leaks and rumours (Timms) that the 2003 US bombing of Al Jazeera was a deliberate attack upon one of the few elements of the public sphere in which some Western-nationality Muslims have confidence, many elements of the mainstream Western media rose to Al Jazeera’s defence. For example, using an appeal to the right of citizens to engage in and consume free speech, the editors of influential US paper The Nation commented that: If the classified memo detailing President Bush’s alleged proposal to bomb the headquarters of Al Jazeera is provided to The Nation, we will publish the relevant sections. Why is it so vital that this information be made available to the American people? Because if a President who claims to be using the US military to liberate countries in order to spread freedom then conspires to destroy media that fail to echo his sentiments, he does not merely disgrace his office and soil the reputation of his country. He attacks a fundamental principle, freedom of the press—particularly a dissenting and disagreeable press—upon which that country was founded. (cited in Scahill) For other Australian Muslims, it is the fact that some media organisations have been listed as banned by the US that gives them their ultimate credibility. This is the case with Al Manar, for example. Feeling that they are denied access to public spaces to partake in democratic dialogue as equal political citizens, Australian Muslims are pursuing alternative communicative spaces that support and reinforce their own cultural worldviews. The act of engaging with marginalised and alternative communicative spaces constitutes what Clifford terms ‘collective practices of displaced dwelling’. It is through these practices of displaced dwelling that Australian Muslims essentialise their diasporic identity and negotiate new identities based on common perceptions of injustice against Muslims. But you look at Al Jazeera they talk in the same tongue as the Western media in our language. And then you look again at something like Al Manar who talks of their own tongue. They do not use the other media’s ideas. They have been attacked by the Australians, been attacked by the Israelis and they have their own opinion. This statement came from an Australian Muslim of Jordanian background in her late forties. It reflects a growing trend towards engaging with media messages that coincide with and reinforce a sense of injustice. The Al Manar television station to which this participant refers is a Lebanese based station run by the militant Hezbollah movement and accessible to Australians via satellite. Much like Al Jazeera, Al Manar broadcasts images of Iraqi and Palestinian suffering and, in the recent war between Israel and Hezbollah, graphic images of Lebanese casualties of Israeli air strikes. Unlike the Al Jazeera broadcasts, these images are formatted into video clips accompanied by music and lyrics such as “we do not fear America”. Despite political pressure including a decision by the US to list Al Manar as a terrorist organisation in December 2004, just one week after a French ban on the station because its programming had “a militant perspective with anti-Semitic connotations” (Jorisch), Al Manar continued to broadcast videos depicting the US as the “mother of terrorism”. In one particularly graphic sequence, the Statue of Liberty rises from the depths of the sea, wielding a knife in place of the torch and dripping in blood, her face altered to resemble a skull. As she rises out of the sea accompanied by music resembling a funeral march the following words in Arabic are emblazoned across the screen: On the dead bodies of millions of native Americans And through the enslavement of tens of millions Africans The US rose It pried into the affairs of most countries in the world After an extensive list of countries impacted by US foreign policy including China, Japan, Congo, Vietnam, Peru, Laos, Libya and Guatamala, the video comes to a gruelling halt with the words ‘America owes blood to all of humanity’. Another video juxtaposes images of Bush with Hitler with the caption ‘History repeats itself’. One website run by the Coalition against Media Terrorism refers to Al Manar as ‘the beacon of hatred’ and applauds the decisions by the French and US governments to ban the station. Al Manar defended itself against the bans stating on its website that they are attempts “to terrorise and silence thoughts that are not in line with the US and Israeli policies.” The station claims that it continues on its mission “to carry the message of defending our peoples’ rights, holy places and just causes…within internationally agreed professional laws and standards”. The particular brand of propaganda employed by Al Manar is gaining popularity among some Muslims in Australia largely because it affirms their own views and opinions and offers them opportunities to engage in an alternative public space in which Muslims are positioned as the victims and not the aggressors. Renegotiating an ‘Othered’ Identity The negative portrayal of Muslims as ‘other’ in the Australian media and in political discourse has resulted in Australian Muslims constructing alternative identities based on a common perception of injustice. Particularly since the terrorist attacks on the World Trade Centre in September 2001 and the ensuing “war on terror”, the ethnic divisions within the Muslim diaspora are becoming less significant as Australian Muslims reconstruct their identity based on a notion of supporting each other in the face of a global alliance against Islam. Religious identity is increasingly becoming the identity of choice for Muslims in Australia. This causes problems, however, since religious identity has no place in the liberal democratic model, which espouses secularism. This is particularly the case where that religion is sometimes constructed as being at odds with the principles and values of liberal democracy; namely tolerance and adherence to the rule of law. This problematic creates a context in which Muslim Australians are not only denied their heterogeneity in the media and political discourse but are dealt with through an understanding of Islam that is constructed on the basis of a cultural and ideological clash between Islam and the West. Religion has become the sole and only characteristic by which Muslims are recognised, denying them political citizenship and access to the public spaces of citizenship. Such ‘essentialising practices’ as eliding considerable diversity into a single descriptor serves to reinforce and consolidate diasporic identity among Muslims in Australia, but does little to promote and assist participatory citizenship or to equip Muslims with the tools necessary to access the public sphere as political citizens of the secular state. In such circumstances, the moderate Muslim may be not so much a ‘preferred’ citizen as one whose rights has been constrained. Acknowledgment This paper is based on the findings of an Australian Research Council Discovery Project, 2005-7, involving 10 focus groups and 60 in-depth interviews. The authors wish to acknowledge the participation and contributions of WA community members. References Akbarzadeh, Shahram, and Bianca Smith. The Representation of Islam and Muslims in the Media (The Age and Herald Sun Newspapers). Melbourne: Monash University, 2005. Aly, Anne, and Mark Balnaves. ”‘They Want Us to Be Afraid’: Developing Metrics of the Fear of Terrorism.” International Journal of Diversity in Organisations, Communities and Nations 6 (2007): 113-122. Aly, Anne. “Australian Muslim Responses to the Discourse on Terrorism in the Australian Popular Media.” Australian Journal of Social Issues 42.1 (2007): 27-40. Clifford, James. Routes: Travel and Translation in the Late Twentieth Century. London: Harvard UP, 1997. Haas, Tanni. “The Public Sphere as a Sphere of Publics: Rethinking Habermas’s Theory of the Public Sphere.” Journal of Communication 54.1 (2004): 178- 84. Jorisch, Avi. J. “Al-Manar and the War in Iraq.” Middle East Intelligence Bulletin 5.2 (2003). Noelle-Neumann, Elisabeth. “The Spiral of Silence: A Theory of Public Opinion.” Journal of Communication 24.2 (1974): 43-52. “Online Archives of California”. California Digital Library. n.d. Feb. 2008 http://content.cdlib.org/ark:/13030/kt1199n498/?&query= %22open%20platform%22&brand=oac&hit.rank=1>. Panopoulos, Sophie. Parliamentary debate, 5 Sep. 2005. Feb. 2008 http://www.aph.gov.au.hansard>. Saniotis, Arthur. “Embodying Ambivalence: Muslim Australians as ‘Other’.” Journal of Australian Studies 82 (2004): 49-58. Scahill, Jeremy. “The War on Al-Jazeera (Comment)”. 2005. The Nation. Feb. 2008 http://www.thenation.com/doc/20051219/scahill>. Timms, Dominic. “Al-Jazeera Seeks Answers over Bombing Memo”. 2005. Media Guardian. Feb. 2008 http://www.guardian.co.uk/media/2005/nov/23/iraq.iraqandthemedia>. Citation reference for this article MLA Style Aly, Anne, and Lelia Green. "‘Moderate Islam’: Defining the Good Citizen." M/C Journal 10.6/11.1 (2008). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0804/08-aly-green.php>. APA Style Aly, A., and L. Green. (Apr. 2008) "‘Moderate Islam’: Defining the Good Citizen," M/C Journal, 10(6)/11(1). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0804/08-aly-green.php>.

Photo ID 129550055 © Katarzyna Bialasiewicz | Dreamstime.com ABSTRACT It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon, and today, about 20 percent of people in the US live in jurisdictions that permit MAiD. The New York State legislature is currently considering a bill that would permit Medical Aid in Dying for terminally ill patients in certain defined circumstances. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions. This demonstrates that legislation can simultaneously grant terminally ill citizens the civil right to access MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. Given the copious evidence gathered in the past decades, concerns about abuse can no longer be credited as grounds for opposing the passage of legislation that is demonstrably both effective and safe. INTRODUCTION It has been 26 years since medical aid in dying (“MAiD”) was first legalized in Oregon,[1] and today, about 20 percent of people in the US live in jurisdictions that permit MAiD.[2] Other jurisdictions, including New York, are actively considering adopting MAiD laws. Those states now benefit from decades of experience, evidence, and reporting from MAiD jurisdictions, demonstrating that legislation can permit MAiD while also aggressively protecting all patients from coercion, manipulation, and harm. The data should allay the concerns of those who oppose MAiD due to the risk of abuse, coercion, and a hypothetical slippery slope. We, as a society, as clinicians, and as ethicists, must remain vigilant and prevent abuse of MAiD, given the potential risks in the community and in congregate care settings and the risk of patient exploitation by family members. However, given the copious evidence, concerns about abuse do not justify opposition to legislation that is effective and safe. I. New York’s MAiD Bill The New York State legislature is currently considering a bill that would permit MAiD for terminally ill patients in defined circumstances.[3] The bill applies only to adults with a terminal illness or condition that is “incurable and irreversible” and “will, within reasonable medical judgment, produce death within six months.” The bill contains numerous protective requirements: MAiD requests can only be made by the patient themself; requests cannot be made by healthcare agents, surrogates, or anyone else; MAiD requests must be made both orally and in writing to the patient’s attending physician; No person is eligible for MAiD solely because of age or disability; The patient’s attending physician must determine the patient has a qualifying terminal illness, has decision-making capacity, and has made a voluntary, informed decision to request MAiD, in the absence of coercion; These determinations must be confirmed by a second consulting physician in writing; If the attending physician has any concern that the patient may not have decision-making capacity, the patient must be referred to a mental health professional; The attending physician has additional duties to the patient, including ensuring the decision is informed, by discussing the patient’s condition and prognosis; discussing the MAiD process, and treatment alternatives like palliative and hospice care; offering referrals to other appropriate treatment, like palliative and hospice care; and educating the patient that their request can be rescinded at any time and offering them an opportunity to do so; The written request must be witnessed by at least two adults who cannot be (i) related to the patient, (ii) entitled to any portion of the patient’s estate, (iii) employed by a healthcare facility where the patient is receiving treatment or residing, (iv) or the attending physician, consulting physician, or mental health professional determining decision-making capacity; and MAiD medication must be self-administered by the patient, and it must be voluntarily ingested.[4] ARGUMENTS FOR AND AGAINST MAiD II. No Evidence of Abuse of Existing MAiD Laws MAiD supporters and critics alike have a concern about the abuse of MAiD. For this reason, MAiD laws throughout the US incorporate strict eligibility criteria and protective procedural requirements. For instance, patients are eligible only if they are terminally ill with six months or less to live, more than one physician must be involved, and requests must be witnessed (by individuals unrelated to the patient who will not profit from the patient’s estate). MAiD requests have been closely examined in the 27 years since Oregon became the first state to legalize the practice. The results show that these compassionate and protective measures have worked. There have been no documented or substantiated incidents of MAiD abuse since Oregon became the first to implement a MAiD law in 1997.[5] In 2019, the executive director of Disability Rights Oregon (DRO), an organization mandated by federal law to investigate complaints of abuse or neglect of people with disabilities, reported that DRO has never received a complaint that a person with disabilities was coerced into obtaining a prescription for MAiD drugs.[6] A recent study of aggregated data from all nine of the US jurisdictions with publicly available MAiD records from 1998 to 2002 found that 95.6 percent of those who died by MAiD were non-Hispanic white individuals, and 53.1 percent were male.[7] 72.2 percent of these individuals had at least some college education, 74 percent had a cancer diagnosis, and the median age of MAiD death was 74 years old. Only 11 percent of patients were uninsured. MAiD users tend to be white, older, educated, diagnosed with cancer, and insured. Fears that MAiD would overwhelmingly be used by (or on) the poor, the uninsured, the uneducated, or racial and ethnic minorities have not materialized. This data has actually raised a converse concern: that MAiD may, inequitably, not be readily available to less privileged populations or those with a diagnosis other than cancer.[8] Opponents of MAiD may argue that the recent relaxation of certain legal restrictions in some jurisdictions is evidence that the slippery slope to unrestricted euthanasia has begun. This is a mischaracterization. Certain restrictions have been adjusted. For instance, Oregon and Vermont removed the residency restriction that previously excluded non-residents from eligibility.[9] Both states changed the residency requirement due to lawsuits challenging the constitutionality of requiring residence.[10] New Jersey’s law will likely change soon, as well.[11] Initial MAiD laws were drafted to be highly restrictive out of concern about unintended and unforeseeable consequences. Given the gravity of the subject, decades ago, it was better to err on the side of caution, even if that meant excluding from eligibility people who ought to, ethically or legally, be included. Now, with nearly 30 years of experience and data, we can better determine which requirements are necessary to appropriately protect patients, clinicians, and society. Restrictions proven to be unnecessary can now be modified. The core purposes of MAiD laws and the rights and protections they provide are not changing. Rather, a few aspects of the regulations are being adjusted so they are not more restrictive than necessary to achieve their purpose. The ever-growing body of evidence that MAiD laws can adequately protect against abuse and the mythic slippery slope has assured many that their fears will not materialize.[12] For example, NYU bioethicist Arthur Caplan was once a vigorous opponent of MAiD. He worried that MAiD laws would lead to the abuse of the poor, uninsured, and disabled in service of cost-saving or the convenience of others. [13] But, after closely following the empirical evidence from MAiD early-adopters, Oregon and Washington, Caplan changed his mind. In 2018, he argued in favor of the NY MAiD bill before the New York State Assembly Standing Committee on Health.[14] Discussing his review of evidence from these states, Caplan stated: I found no cause for my concerns, none with respect to the slippery slope. There isn’t solid evidence of coercion or duplicity being exercised with respect to people who choose assistance in dying in either state. The police, government officials, families of those who have chosen to use the legislation and the general citizenry find no causes or basis for changing the laws due to abuse or misapplication . . . These slippery slope arguments are just not true . . . there is no current factual support for this slippery slope argument that vulnerable individuals are at risk for being coerced into using the law.[15] Decades of evidence has shown that legislation can simultaneously grant terminally ill patients access to MAiD while also protecting against coercion and abuse. In the face of this evidence, continuing to deny access to MAiD because of hypothetical abuse is unjust and unethical. III. Views of Opponents are Neither Grounded in Fact nor Consistent with Current End-of-Life Practices a. Risk of coercion One common argument heard today from some disability advocates who oppose MAiD goes something like this: Everybody who would qualify for and use MAiD is (or will become) a disabled person, so MAiD only kills people with disabilities. The most common reasons people choose to end their lives via MAiD are disability issues, like loss of autonomy, less ability to engage in activities, and loss of dignity. They argue that, instead of making it easier for disabled people to die, we should make sure that proper services and support exist so that disabled people do not choose to die. Such disability-rights-based arguments tend to assert that to avoid abuse, we must prohibit MAiD altogether. They argue that legalizing MAiD will inexorably lead to abuse and coercion, and disabled people will be pressured into suicide. Some even argue that MAiD laws are the first step to euthanasia, noting the path in other jurisdictions.[16] As an initial matter, people with disabilities deserve adequate support and services, and these are not always available to them. People with disabilities have faced tremendous discrimination in the healthcare system and have been historically prevented from accessing proper care and asserting their autonomy. Ensuring that all can access adequate end-of-life care, like palliative or hospice care, is an ongoing battle that ought not be abandoned. But fighting for adequate end-of-life care and legalizing MAiD are not mutually exclusive. In Oregon, 90 percent of those who access MAiD are enrolled in hospice and states with MAiD laws tend to have better access to palliative care than states without.[17] MAiD proponents seek only to add another choice for the dying, not to diminish any other options. This is reflected in the text of New York’s pending bill, which explicitly requires patient education and referrals to appropriate end-of-life services, like palliative care and hospice.[18] No one has openly argued that society should hold terminally ill patients hostage in order to obtain broader support and funding for palliative care, but that is the practical effect. Beyond the need for supportive services and proper access to the full range of end-of-life care options, the disability argument fails. First, the assertion that MAiD laws will be abused and disabled people will be coerced into suicide is not grounded in fact. To the contrary, real-life evidence gathered in over two decades of legal MAiD has shown no documented or substantiated incidents of abuse, as discussed above.[19] The slippery slope has simply not materialized. Advocates for people with disabilities who are opposed to MAiD have not clearly articulated exactly who is vulnerable to being coerced into obtaining a MAiD prescription or even how such coercion could logistically occur. Most people with disabilities are not vulnerable to MAiD abuse, as they do not have a qualifying terminal illness or lack decisional capacity due to a developmental disability and are therefore not eligible. MAiD opponents appear to be claiming that all those who qualify for MAiD are vulnerable and seek protection from MAiD laws. But this would include many of the people that, over the past decades, have aggressively and publicly advocated for access to MAiD – terminally ill people, like Brittany Maynard,[20] many of whom lobbied hard for the passage of MAiD laws while knowing that they themselves would die before the laws passed. Opponents of MAiD from a segment of the disability rights community are telling individuals who they claim, without permission, as members of the MAiD opposition community, that they must all endure unimaginable suffering without a MAiD option because they must be protected from theoretical coercive harm. People with disabilities should be allowed to make their own choices. No one, not even the most well-meaning advocate, should be allowed to obstruct a patient’s end-of-life choices – those choices belong to the patient alone. b. Argument That the Demand for MAID is a Result of Poor Disability Services Second, the argument that terminally ill patients would decline MAiD if only they had better disability services or support is disingenuous to the extent that it ignores the fact that people choosing MAiD are actively dying. No provision of supportive services can change this. And it is perfectly reasonable for someone who knows that they will die in less than six months to want some control over the manner of their death and to avoid the deterioration, indignity, and suffering that could come with it. The argument construes a MAiD death as a choice to die rather than live with a disability. But individuals choosing MAiD are not choosing death – death is coming and coming quickly. MAiD simply offers some control over this reality, giving patients an option that is safe, certain, and painless. Certainly, supportive hospice services should be available for these individuals. But there is no evidence demonstrating that any amount of service would eliminate the need and desire for the MAiD option. c. Inconsistent Positions on MAID and Other Ending Life Care Options: Palliative Sedation and VSED MAiD opponents who are concerned about abuse and coercion often hold inconsistent views on other currently available ending life care options.[21] For example, some argue that palliative sedation[22] renders MAiD unnecessary and does not present the same ethical problems.[23] However, whereas MAiD can only be chosen by the patient themself (and the patient must have decision-making capacity), the same is not true for palliative sedation. Palliative sedation, a valuable modality of end-of-life care, does not have to be initiated by the patient. If the patient is deemed not to have decision-making capacity to make that decision, their healthcare proxy can decide to initiate the process and continue it until the patient dies. Individuals other than patients often choose to begin palliative sedation and continue it to its inevitable conclusion. And because palliative sedation does not require enabling legislation, none of the protective safeguards incorporated in MAiD legislation are available to protect those who receive palliative sedation. Some may try to differentiate between palliative sedation and MAiD by saying that once started, palliative sedation can always be discontinued – it need not end in the patient’s death. This is true, but the very process of palliative sedation will inevitably make the patient insensible or unconscious or otherwise unable to exercise a choice to stop sedation. With MAiD, the patient must self-administer and ingest the medication on their own, with death following quickly. The patient can choose to forgo MAID up until the very moment of self-administration. Considering MAiD’s procedural safeguards, including that only the patient may choose and administer MAiD, MAiD patients are offered more protection from potential abuse than patients who receive palliative sedation. While some have vocally opposed MAiD for decades, there has not been similar opposition to the option of voluntarily stopping eating and drinking (VSED). With VSED, adults with decision-making capacity make a voluntary decision to refuse nutrition and hydration to die more quickly. People choosing VSED are, essentially, making the same choice that people choosing MAiD do. But VSED is a less predictable process that takes much longer to complete. Unfortunately, the process also carries a risk of unpleasant side-effects, though proper care can help mitigate them. Additionally, the practice of VSED is not constrained by statutorily defined protective measures, as is the case with MAiD – one does not even need to have a terminal illness to choose VSED.[24] It is logically inconsistent for those who oppose MAiD because of the perceived potential of abuse to hold different views about VSED.[25] If malevolent actors can unethically pressure or coerce patients into MAiD, they can also coerce them to stop eating and drinking. As with palliative sedation, it could be argued that an important difference is that VSED can be stopped, unlike MAiD. This argument fails clinically and ethically. As with palliative sedation, the VSED process eventually results in the patient losing consciousness and decision-making capacity. The patient generally becomes unarousable for a period that could last for days or even weeks. For this reason, it is crucial for VSED patients to express their choice in writing (or preferably in video recording)[26] to ensure that they will not be given nutrition or hydration when they are no longer able to enforce their refusal (or if they begin asking for nutrition or hydration). Therefore, there is a period in which the patient cannot decide to end the process, just as with palliative sedation. To the extent that someone is so concerned with potential abuse of MAiD that they seek to ban it but have not expressed similar concerns with VSED, these positions are inconsistent. At a NYS Bar Association-sponsored conference on MAiD in 2019, David Hoffman asked a MAiD opponent whether, “as someone who is looking out for the interests of a segment of the disability population,” she supports palliative sedation and VSED.”[27] Kathryn Carroll, who represented the Center for Disability Rights (“CDR”), confirmed that CDR did not oppose palliative sedation and did not offer a position on VSED. She noted the subtle difference in intention: I don’t believe the Center for Disability Rights has taken issue with palliative sedation. And my understanding is that there is a key difference between palliative sedation and assisted suicide, particularly in that palliative sedation, the point is not to bring about the death of the person, but to relieve the pain that they are experiencing. And so the death is more of a side effect rather than the intended outcome.[28] During the questioning, she provided no explanation as to why the potential for abuse would be different among palliative sedation, VSED, and MAiD.[29] The other MAiD opponent on the panel, Dennis Vacco, of Vacco v. Quill[30] fame, interjected but could not explain any ethically significant difference between VSED and MAiD. Instead, he focused solely on palliative sedation, stating that the relevant difference is that palliative sedation can be stopped: . . . treating the pain including what you referred to as terminal sedation, is not moral and legally and ethnically the same as physician-assisted suicide . . . The fact of the matter is – the difference is you can terminate that treatment, and it’s the permanent aspect of physician-assisted suicide that goes back to what I said 20 minutes ago. You can’t put the bright line anyplace else other than where it is.[31] But, as discussed above, that difference is of little import, given that palliative sedation results in patients without the ability or capacity to make the choice to stop treatment. Vacco then reverted to his concerns about the potential for coercion and the elusive slippery slope, referencing his primary argument that the only way to ensure there is no abuse of a MAiD law is not to have one at all: The bright line that is created by the law in the state of New York, which makes physician-assisted suicide a manslaughter in the second-degree, or assisting suicide by anybody, manslaughter in the second degree . . . is unfortunately the only place that line can be. That line should not move further toward accommodation. And we see here in the context of . . . all of the so-called protections in the statute. With every protection that is not prohibition, with every protection, you raise the possibility of abuse. You raise the possibility with every protection.[32] Neither Vacco nor Carroll addressed the fact that many common practices today can be the result of coerced decisions. These practices have none of the safeguards contained in MAiD legislation. As another panelist, David Leven, stated: consider that people who want to have life-sustaining treatment withdrawn, whether it’s a ventilator or feeding tube, they can also be coerced by family members. That can happen even more often, of course, because that process takes place more and more often, and there are none of the safeguards that we’re talking about here . . . there are risks involved in any process which might result in a hastened death. But there seems to be very little risk involved with medical aid in dying based on the experience in 40 years and the nine states which now permit medical aid in dying.[33] There is an inescapable inconsistency within the disability argument: one cannot logically be so concerned about the abuse of legalized access to MAiD to justify opposing all MAiD legislation while simultaneously supporting options like palliative sedation or VSED as abuse-free alternatives. d. Argument Against Speaking for a Community with Diverse Views Finally, while some disability advocates opposing MAiD will claim terminally ill patients as part of their community, they have no right or authorization to speak for the extremely heterogeneous group of terminally ill patients or the disability community[34] as a whole. The disability community is not homogenous; while some members oppose MAiD, others support it.[35] Recent polling indicates that MAiD may have broad support across the disability community.[36] e. MAiD Opponents Hold the Rights of the Terminally Ill Subordinate to Their Personal Morality and Unsubstantiated Theoretical Concerns The argument that does not get much attention, the one that is the simplest and perhaps even the most compelling, is that all killing is wrong, and the government ought not to be in the business of enabling it. That is certainly a compelling religious and moral argument against individuals engaging in any form of acts that result in ending a human life. But such an ethical or theological position does not dictate that individuals who hold different views on personal morality should be precluded by the state from accessing the most safe, certain, and painless means of addressing an invariably terminal illness. Arguments like the one described above by Vacco (that the only way to completely avoid potential MAiD abuse is to prohibit MAiD) are essentially claiming that the safest thing to do is to subordinate the suffering of the terminally ill to avoid the more subtle task of balancing the interests of two different groups of New York state citizens. But surely, that is the role of the legislature every day. And we should expect no less from the legislature on this issue. The best way to ensure no one dies in car accidents is to prohibit driving. But instead of doing so, we implement safety regulations (like speed limits) to balance the right to travel with the right of everyone else not to be killed in the process. Evidence demonstrates that MAiD legislation can also strike a balance between the rights of the terminally ill and the need to prevent harm. It is not justifiable to support a blanket prohibition of MAiD. CONCLUSION Opponents of MAiD have had decades to cite problematic case studies or formulate a compelling moral argument against it that is grounded in data rather than an assertion of their personal morality. Plainly, no one on either side of the MAiD legislative discussion wants to see anyone subjected to involuntary euthanasia or coerced into MAiD as a better alternative to palliative care when such a plan of care is a viable alternative to “ending life care.” However, enough time has passed, and the risk of coercion has been given sufficient study and debate that we can now conclude, as a society, that the rights of the terminally ill and the rights of persons committed to living their best and longest life with a disability are wholly compatible. It is time for the legislature to strike the appropriate balance and give the terminally ill a well-regulated, responsible pathway to obtaining medication that can relieve their suffering in a manner that is safe, certain, and painless. - [1] Oregon’s Death with Dignity Act, Oregon Health Authority, https://www.oregon.gov/oha/ph/providerpartnerresources/evaluationresearch/deathwithdignityact/pages/index.aspx [2] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States, 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925 [3] Medical Aid in Dying Act, A.995-A, N.Y. St. Assemb. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A; see also, Medical Aid in Dying Act, S.2445-A, N.Y. St. Senate (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/S2445A. [4] Id. [5] Ronald A. Lindsay, Oregon’s Experience: Evaluating the Record, 9 The American Journal of Bioethics 19 (2009), https://doi.org/10.1080/15265160802654137; Christopher A. Riddle, Medical Aid in Dying: The Case of Disability, in New Directions in the Ethics of Assisted Suicide and Euthanasia 234 (Michael Cholbi & Jukka Varelius eds., 2nd ed. 2023), https://doi.org/10.1007/978-3-031-25315-7; Health Law Section: Duties, Rights & the Law at the End of Life (2019), NY ST. BAR ASSOC. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/; Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1; Fact: Medical Aid in Dying Laws Work to Protect Patients. (n.d.). Compassion & Choices. Retrieved September 5, 2023, from https://compassionandchoices.org/resource/fact-medical-aid-in-dying-laws-work-to-protect-patients; Frequently Asked Questions. (2021, December 7). Death With Dignity. https://deathwithdignity.org/resources/faqs/. [6] Bob Joondeph, Letter from Disability Rights Oregon (DRO), Compassion & Choices (Feb. 14, 2019), https://www.compassionandchoices.org/docs/default-source/default-document-library/disability-rights-oregon-dwd-letter-2-14-19.pdf. [7] Elissa Kozlov et al., Aggregating 23 Years of Data on Medical Aid in Dying in the United States, 70 Journal of the American Geriatrics Society 3040 (2022). https://doi.org/10.1111/jgs.17925 [8] Id. [9] Medical Aid in Dying: Act 39: Patient Choice and Control at the End of Life, Vermont Ethics Network, https://vtethicsnetwork.org/palliative-and-end-of-life-care/medical-aid-in-dying-act-39 (last visited Sept. 21, 2023). [10] Gideonse v. Brown, No. 3:21-cv-01568-AC (D. Or.); Bluestein v. Scott, No. 2:22-cv-00160 (D. Vt.). [11] Govatos v. Murphy, No. 2:23-cv-12601(D.N.J.). [12] Medical associations, historically opponents of MAiD, have begun adopting neutral positions, reflecting changing attitudes of the medical community. E.g., California Medical Association removes opposition to physician aid in dying bill, California Medical Association (May 20, 2015), https://www.cmadocs.org/newsroom/news/view/ArticleId/27210/California-Medical-Association-removes-opposition-to-physician-aid-in-dying-bill; Board directs CMS to develop and distribute “End-of-Life Act” education to members, Colorado Medical Society (November 22, 2016), https://www.cms.org/articles/board-directs-cms-to-develop-and-distribute-end-of-life-act-education-to-me; Vermont Medical Society Policy on End-of-life-Care, Vermont Medical Society (2017), https://vtmd.org/client_media/files/vms_resolutions/2017End-of-Life-Care.pdf (last accessed Sept. 21, 2023); but see Physician-Assisted Suicide, AMA Code of Ethics, https://code-medical-ethics.ama-assn.org/ethics-opinions/physician-assisted-suicide. (5.7 provides opinion opposing MAiD; opinion 1.1.7 provides opinion on conscientious objection.); The American Medical Association could vote to change its stance on medical aid in dying, Death with Dignity (Nov. 10, 2023), https://deathwithdignity.org/news/2023/11/ama-could-vote-to-change-stance-on-maid/ (Update notes that the AMA did not change its stance from opposed to neutral at its November 2023 interim meeting in Baltimore, but referred the resolutions for further study). [13] Medical Aid in Dying: Hearing on A.2383-A Before the New York State Assembly Standing Committee on Health (2018) (testimony of Arthur Caplan), transcript available at https://nystateassembly.granicus.com/DocumentViewer.php?file=nystateassembly_bc5bd4afc9fd8b9021781bc9e35e15ae.pdf&view=1. [14] Id. [15] Id. [16] Id. (noting the laws in Netherlands, Belgium and Canada.); see also National Council on Disability, The danger of assisted suicide laws: Part of the Bioethics and Disability series (2019). https://ncd.gov/sites/default/files/NCD_Assisted_Suicide_Report_508.pdf. [17] Sean Riley & Ben Sarbey, The unexamined benefits of the expansive legalization of medical assistance-in-dying, 19 J. Bioethical Inquiry 4, 663 (2022) (citing Oregon Health Authority Center for Health Statistics, Oregon Death with Dignity Act: 2018 Data Summary (2019), https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf and R. Sean Morrison, et al., America’s care of serious illness: A state-by-state report card on access to palliative care in our nation’s hospitals, 14 J. Palliat. Med. 10, 1094–1096 (2011)). [18] Medical Aid in Dying Act, A.995-A, N.Y. St. Assembly. (2023), available at https://legislation.nysenate.gov/pdf/bills/2023/A995A [19] See also, Ben Colburn, Disability‐based Arguments against Assisted Dying Laws, 36 Bioethics 680 (2022) (cataloging research in multiple countries and concluding that “there is no evidence that assisted dying laws have a disproportionate effect on people with disabilities”). https://doi.org/10.1111/bioe.13036 [20] Eyder Peralta, As Planned, Right-To-Die Advocate Brittany Maynard Ends Her Life, NPR (Apr. 3, 2014), https://www.npr.org/sections/thetwo-way/2014/11/03/361094919/as-planned-right-to-die-advocate-brittany-maynard-ends-her-life (Activist Brittany Maynard moved to Oregon after she was diagnosed with a malignant brain tumor, because her home state did not permit MAiD at the time). [21] Ending life care is defined as the final stage of the end-of-life care continuum, where the patient chooses to end their life as a means to end their suffering or unacceptable quality of life. [22] Palliative sedation is defined as “the use of medications to induce decreased or absent awareness in order to relieve otherwise intractable suffering at the end of life,” and it carries a risk of hastening death. Molly L. Olsen, Keith M. Swetz & Paul S. Mueller, Ethical Decision Making With End-of-Life Care: Palliative Sedation and Withholding or Withdrawing Life-Sustaining Treatments, 85 Mayo Clin Proc 949 (2010). https://doi.org/10.4065/mcp.2010.0201 [23] E.g. Disability Rights Toolkit for Advocacy Against Legalization of Assisted Suicide, Not Dead Yet, https://notdeadyet.org/disability-rights-toolkit-for-advocacy-against-legalization-of-assisted-suicide (last visited Dec. 8, 2023) (describing palliative sedation as “a legal solution to any remaining painful and uncomfortable deaths; one that does not raise the very serious hazards of legalizing assisted suicide”); Testimony of CDR’s Kathryn Carroll, Esq. Opposing NY Assisted Suicide Bill A2383A, Not Dead Yet (Apr. 23, 2018), https://notdeadyet.org/testimony-of-cdrs-kathryn-carroll-esq-opposing-ny-assisted-suicide-bill-a2383a. [24] Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001 [25] This is not to say that MAiD and VSED are ethically identical. Different writers have articulated various reasons why MAiD and VSED are meaningfully different and meaningfully similar. Here we distinguish the potential for abuse, as this is the argument that persists among MAiD opponents, For a broader discussion on the ethics of VSED and how it compares to MAiD, see Voluntarily Stopping Eating and Drinking: A Compassionate, Widely-Available Option for Hastening Death, (Timothy E. Quill et al. eds., 2021). https://doi.org/10.1093/med/9780190080730.001.0001 [26] Id.; see also David N. Hoffman and Judy Schwarz, Can Patients Choose to Stop Eating–Even If They Have Dementia–and Can Health Care Facilities Get Paid for Taking Care of Them? Ethics and Reimbursement at the End of Life (Am. Health L. Ass’n Conf. on Long Term Care and the Law 2020). [27] Health Law Section: Duties, Rights & the Law at the End of Life (2019), NY St. Bar Assoc. (Nov. 8, 2019), https://nysba.org/products/health-law-section-duties-rights-the-law-at-the-end-of-life-2019/. [28] Id. [29] CDR still does not appear to have articulated a position on VSED. CDR is a major and vocal opponent of MAiD legislation in NY with considerable resources (they state their projected 2010 budget was approximately $29,000,000). About Us, Center for Disability Rights, https://cdrnys.org/about/. [30] Vacco v. Quill, 521 U.S. 793 (1997) (holding that there is no equal protection violation when N.Y. law criminalized assisted-suicide but permitted removal of life-support systems). [31] Health Law Section: Duties, Rights & the Law at the End of Life (2019), supra note 5. [32] Id. [33] Id. [34] Ben Colburn, Disability‐based Arguments against Assisted Dying Laws, 36 Bioethics 680 (2022) (providing evidence that “that people with disabilities, and disability rights organizations, have diverse views on the question of whether assisted dying should be legal”). https://doi.org/10.1111/bioe.13036 [35] Us for Autonomy, https://www.usforautonomy.org (last visited Sep 10, 2023); see also, Kathryn L. Tucker, Building Bridges Between the Civil Rights Movements of People with Disabilities and Those with Terminal Illness, 78 U. of Pitt. L. Rev. 329 (2017) (collecting and describing amici participation by disability advocates supporting end-of-life liberty). https://doi.org/10.5195/lawreview.2017.473 [36] E.g., USA/National Public Opinion Survey, Susquehanna Polling & Research, Inc. (Feb. 2023),https://d31hzlhk6di2h5.cloudfront.net/20230307/2e/9e/21/14/d37db7887f3f349202ae6f31/Raben_Crosstabulation_Report_2023.FINAL%20(1).pdf ).

Photo by 14825144 © Alita Xander | Dreamstime.com ABSTRACT The US government's approach to the War on Drugs has created laws to deter people from using illicit drugs through negative punishment. These laws have not controlled illicit drug use, nor has it stopped the opioid pandemic from growing. Instead, these laws have created a negative bias surrounding addiction and have negatively affected particularly vulnerable patient populations, including pregnant women with substance use disorder and newborns with neonatal abstinence syndrome. This article highlights some misconceptions and underscores the challenges they face as they navigate the justice and healthcare systems while also providing possible solutions to address their underlying addiction. INTRODUCTION Pregnant women with substance use disorder require treatment that is arguably for the benefit of both the mother and the fetus. Some suggest that addiction is a choice; therefore, those who misuse substances should not receive treatment. Proponents of this argument emphasize social and environmental factors that lead to addiction but fail to appreciate how chronic substance use alters the brain’s chemistry and changes how it responds to stress, reward, self-control, and pain. The medical community has long recognized that substance use disorder is not simply a character flaw or social deviance, but a complex condition that requires adequate medical attention. Unfortunately, the lasting consequences of the War on Drugs have created a stigma around addiction medicine, leading to significant treatment barriers. There is still a pervasive societal bias toward punitive rather than rehabilitative approaches to addiction. For example, many women with substance use disorder lose custody of their baby or face criminal penalties, including fines and jail time.[1] These punitive measures may cause patients to lose trust in their physicians, ultimately leading to high-risk pregnancies without prenatal care, untreated substance misuse, and potential lifelong disabilities for their newborns.[2] As a medical student, I have observed the importance of a rehabilitative approach to addiction medicine. Incentivizing pregnant women with substance use disorder to safely address their chronic health issues is essential for minimizing negative short-term and long-term outcomes for women and their newborns. This approach requires an open mind and supportive perspective, recognizing that substance use disorder is truly a medical condition that requires just as much attention as any other medical diagnosis.[3] BACKGROUND The War on Drugs was a government-led initiative launched in 1970 by President Richard M. Nixon with the aim of curtailing illegal drug use, distribution, and trade by imposing harsher prison sentences and punishments.[4] However, it is worth noting that one can trace the roots of this initiative back further. In 1914, Congress enacted the Harrison Narcotics Tax Act to target the recreational use of drugs such as morphine and opium.[5] Despite being in effect for over four decades, the War on Drugs failed to achieve its intended goals. In 2011, the Global Commission on Drug Policy released a report that concluded that the initiative had been futile, as “arresting and incarcerating tens of millions of these people in recent decades has filled prisons and destroyed lives and families without reducing the availability of illicit drugs or the power of criminal organizations.”[6] One study published in the International Journal of Drug Policy in the same year found that funding drug law enforcement paradoxically contributed to increasing gun violence and homicide rates.[7] The Commission recommended that drug policies focus on reducing harm caused by drug use rather than solely on reducing drug markets. Recognizing that many drug policies were of political opinion, it called for drug policies that were grounded in scientific evidence, health, security, and human rights.[8] Unfortunately, policy makers did not heed these recommendations. In 2014, Tennessee’s legislature passed a “Fetal Assault Law,” which made it possible to prosecute pregnant women for drug use during pregnancy. If found guilty, pregnant women could face up to 15 years in prison and lose custody of their child. Instead of deterring drug use, the law discouraged pregnant women with substance use disorder from seeking prenatal care. This law required medical professionals to report drug use to authorities, thereby compromising the confidentiality of the patient-physician relationship. Some avoided arrest by delivering their babies in other states or at home, while others opted for abortions or attempted to go through an unsafe withdrawal prior to receiving medical care, sacrificing the mother's and fetus's wellbeing. The law had a sunset provision and expired in 2016. During the two years this law was in effect, officials arrested 124 women.[9] The fear that this law instilled in pregnant women with substance use disorder can still be seen across the US today. Many pregnant women with substance use disorders stated that they feared testing positive for drugs. Due to mandatory reporting, they were not confident that physicians would protect them from the law.[10] And if a woman tried to stop using drugs before seeking care to avoid detection, she often ended up delaying or avoiding care.[11] The American College of Obstetricians and Gynecologists (ACOG) recognizes the fear those with substance use disorders face when seeking appropriate medical care and emphasizes that “obstetric–gynecologic care should not expose a woman to criminal or civil penalties, such as incarceration, involuntary commitment, loss of custody of her children, or loss of housing.”[12] Mandatory reporting strains the patient-physician relationship, driving a wedge between the doctor and patient. Thus, laws intended to deter people from using substances through various punishments and incarceration may be doing more harm than good. County hospitals that mainly serve lower socioeconomic patients encounter more patients without consistent health care access and those with substance use disorders.[13] These hospitals are facing the consequences of the worsening opioid pandemic. At one county hospital where I recently worked, there has been a dramatic increase in newborns with neonatal abstinence syndrome born to mothers with untreated substance use disorders during pregnancy. Infants exposed to drugs prenatally have an increased risk of complications, stillbirth, and life-altering developmental disabilities. At the hospital, I witnessed Child Protective Services removing two newborns with neonatal abstinence syndrome from their mother’s custody. Four similar cases had occurred in the preceding month. In the days leading up to their placement with a foster family, I saw both newborns go through an uncomfortable drug withdrawal. No baby should be welcomed into this world by suffering like that. Yet I felt for the new mothers and realized that heart-wrenching custody loss is not the best approach. During this period, I saw a teenager brought to the pediatric floor due to worsening psychiatric symptoms. He was born with neonatal abstinence syndrome that neither the residential program nor his foster family could manage. His past psychiatric disorders included attention deficit disorder, conduct disorder, major depressive disorder, anxiety disorder, disruptive mood dysregulation disorder, intellectual developmental disorder, and more. During his hospitalization, he was so violent towards healthcare providers that security had to intervene. And his attitude toward his foster parents was so volatile that we were never sure if having them visit was comforting or agitating. Throughout his hospital course, it was difficult for me to converse with him, and I left every interview with him feeling lost in terms of providing an adequate short- and long-term assessment of his psychological and medical requirements. What was clear, however, was that his intellectual and emotional levels did not match his age and that he was born into a society that was ill-equipped to accommodate his needs. Just a few feet away from his room, behind the nurses’ station, were the two newborns feeling the same withdrawal symptoms that this teenager likely experienced in the first few hours of his life. I wondered how similar their paths would be and if they would exhibit similar developmental delays in a few years or if their circumstance may follow the cases hyped about in the media of the 1980s and 1990s regarding “crack babies.” Many of these infants who experienced withdrawal symptoms eventually led normal lives.[14] Nonetheless, many studies have demonstrated that drug use during pregnancy can adversely impact fetal development. Excessive alcohol consumption can result in fetal alcohol syndrome, characterized by growth deficiency, facial structure abnormalities, and a wide range of neurological deficiencies.[15] Smoking can impede the development of the lungs and brain and lead to preterm deliveries or sudden infant death syndrome.[16] Stimulants like methamphetamine can also cause preterm delivery, delayed motor development, attention impairments, and a wide range of cognitive and behavioral issues.[17] Opioid use, such as oxycodone, morphine, fentanyl, and heroin, may result in neonatal opioid withdrawal syndrome, in which a newborn may exhibit tremors, irritability, sleeping problems, poor feeding, loose stools, and increased sweating within 72 hours of life.[18] In 2014, the American Association of Pediatrics (AAP) reported that one newborn was diagnosed with neonatal abstinence syndrome every 15 minutes, equating to approximately 32,000 newborns annually, a five-fold increase from 2004.[19] The AAP found that the cost of neonatal abstinence syndrome covered by Medicaid increased from $65.4 million to $462 million from 2004 to 2014.[20] In 2020, the CDC published a paper that showed an increase in hospital costs from $316 million in 2012 to $572.7 million in 2016.[21] Currently, the impact of the COVID-19 pandemic on the prevalence of newborns with neonatal abstinence syndrome is unknown. I predict that the increase in opioid and polysubstance use during the pandemic will increase the number of newborns with neonatal abstinence syndrome, thereby significantly increasing the public burden and cost.[22] In the 1990s, concerns arose about the potentially irreparable damage caused by intrauterine exposure to cocaine on the development of infants, which led to the popularization of the term “crack babies.”[23] Although no strong longitudinal studies supported this claim at the time, it was not without merit. The Maternal Lifestyle Study (NCT00059540) was a prospective longitudinal observational study that compared the outcomes of newborns exposed to cocaine in-utero to those without.[24] One of its studies revealed one month old newborns with cocaine exposure had “lower arousal, poorer quality of movements and self-regulation, higher excitability, more hypertonia, and more nonoptimal reflexes.”[25] Another study showed that at one month old, heavy cocaine exposure affected neural transmission from the ear to the brain.[26] Long-term follow up from the study showed that at seven years old, children with high intrauterine cocaine exposure were more likely to have externalizing behavior problems such as aggressive behavior, temper tantrums, and destructive acts.[27] While I have witnessed this behavior in the teenage patient during my pediatrics rotation, not all newborns with intrauterine drug exposure are inevitably bound to have psychiatric and behavioral issues later in life. NPR recorded a podcast in 2010 highlighting a mother who used substances during pregnancy and, with early intervention, had positive outcomes. After being arrested 50 times within five years, she went through STEP: Self-Taught Empowerment and Pride, a public program that allowed her to complete her GED and provided guidance and encouragement for a more meaningful life during her time in jail. Her daughter, who was exposed to cocaine before birth, had a normal childhood and ended up going to college.[28] From a public health standpoint, more needs to be done to prevent the complications of substance misuse during pregnancy. Some states consider substance misuse (and even prescribed use) during pregnancy child abuse. Officials have prosecuted countless women across 45 states for exposing their unborn children to drugs.[29] With opioid and polysubstance use on the rise, the efficacy of laws that result in punitive measures seems questionable.[30] So far, laws are not associated with a decrease in the misuse of drugs during pregnancy. Millions of dollars are being poured into managing neonatal abstinence syndrome, including prosecuting women and taking their children away. Rather than policing and criminalizing substance use, pregnant women should get the appropriate care they need and deserve. I. Misconception One: Mothers with Substance Use Disorder Can Get an Abortion If an unplanned pregnancy occurs, one course of action could be to terminate the pregnancy. On the surface, this solution seems like a quick fix. However, the reality is that obtaining an abortion can be challenging due to two significant barriers: accessibility and mandated reporting. Abortion laws vary by state, and in Tennessee, for instance, abortions are banned after six weeks of gestation, typically when fetal heart rhythms are detected. An exception to this is in cases where the mother's life is at risk.[31] Unfortunately, many women with substance use disorders are from lower socioeconomic backgrounds and cannot access pregnancy tests, which could indicate they are pregnant before the six-week cutoff. If a Tennessee woman with substance use disorder decides to seek an abortion after six weeks, she may need to travel to a neighboring state. However, this is not always a feasible option, as the surrounding states (WV, MO, AR, MI, AL, and GA) also have restrictive laws that either prohibit abortions entirely or ban them after six weeks. Moreover, she may be hesitant to visit an obstetrician for an abortion, as some states require physicians by law to report their patients' substance use during pregnancy. For example, Virginia considers substance use during pregnancy child abuse and mandates that healthcare providers report it. This would ultimately limit her to North Carolina if she wants to remain in a nearby state, but she must go before 20 weeks gestation.[32] For someone who may or may not have access to reliable transportation, traveling to another state might be impossible. Without resources or means, these restrictive laws have made it incredibly difficult to obtain the medical care they need. II. Misconception Two: Mothers with SUD are Not Fit to Care for Children If a woman cannot take care of herself, one might wonder how she can take care of another human being. Mothers with substance use disorders often face many adversities, including lack of economic opportunity, trauma from abuse, history of poverty, and mental illness.[33] Fortunately, studies suggest keeping mother and baby together has many benefits. Breastfeeding, for example, helps the baby develop a strong immune system while reducing the mother’s risk of cancer and high blood pressure.[34] Additionally, newborns with neonatal abstinence syndrome who are breastfed by mothers receiving methadone or buprenorphine require less pharmacological treatment, have lower withdrawal scores, and experience shorter hospital stays.[35] Opioid concentration in breastmilk is minimal and does not pose a risk to newborns.[36] Moreover, oxytocin, the hormone responsible for mother-baby bonding, is increased in breastfeeding mothers, reducing withdrawal symptoms and stress-induced reactivity and cravings while also increasing protective maternal instincts.[37] Removing an infant from their mother’s care immediately after birth would result in the loss of all these positive benefits for both the mother and her newborn. The newborns I observed during my pediatrics rotation probably could have benefited from breastfeeding rather than bottle feeding and being passed around from one nurse to the next. They probably would have cried less and suffered fewer withdrawal symptoms had they been given the opportunity to breastfeed. And even if the mothers were lethargic and unresponsive while going through withdrawal, it would still have been possible to breastfeed with proper support. Unfortunately, many believe mothers with substance use disorder cannot adequately care for their children. This pervasive societal bias sets them up for failure from the beginning and greatly inhibits their willingness to change and mend their relationship with their providers. It is a healthcare provider’s duty to provide non-judgmental care that prioritizes the patient’s well-being. They must treat these mothers with the same empathy and respect as any other patient, even if they are experiencing withdrawal. III. Safe Harbor and Medication-Assisted Treatment Addiction is like any other disease and society should regard treatment without stigma. There is no simple fix to this problem, given that it involves the political, legal, and healthcare systems. Punitive policies push pregnant women away from receiving healthcare and prevent them from receiving beneficial interventions. States need to enact laws that protect these women from being reported to authorities. Montana, for example, passed a law in 2019 that provides women with substance use disorders safe harbor from prosecution if they seek treatment for their condition.[38] Medication-assisted treatment with methadone or buprenorphine is the first line treatment option and should be available to all pregnant women regardless of their ability to pay for medical care.[39] To promote continuity of care, health officials could include financial incentives to motivate new mothers to go to follow-up appointments. For example, vouchers for groceries or enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) may offset financial burdens and allow a mother to focus on taking care of her child and her recovery. IV. Mandated Substance Abuse Programs Although the number of people sentenced to state prisons for drug related crimes has been declining, it is still alarming that there were 171,300 sentencings in 2019.[40] Only 11 percent of the 65 percent of our nation’s inmates with substance use disorder receive treatment, implying that the other 89 percent were left without much-needed support to overcome their addiction.[41] It is erroneous to assume that their substance use disorder would disappear after a period without substance use while behind bars. After withdrawal, those struggling with substance use disorder may still have cravings and the likelihood of relapsing remains high without proper medical intervention. Even if they are abstinent for some time during incarceration, the underlying problem persists, and the cycle inevitably continues upon release from custody. In line with the recommendations by Global Commission on Drug Policy and the lessons learned from the failed War on Drugs, one proposed change in our criminal justice system would be to require enrollment and participation in assisted alcohol cessation programs before legal punishment. Policy makers must place emphasis on the safety of the patient and baby rather than the cessation of substance use. This would incentivize people to actively seek medical care, restore the patient-physician relationship, and ensure that they take rehabilitation programs seriously. If the patient or baby is unsafe, a caregiver could intervene while the patient re-enrolls in the program. Those currently serving sentences in prisons and jails can treat their substance use disorder through medication assisted treatment, cognitive behavioral therapy, and programs like Self Taught Empowerment and Pride (STEP). Medication assisted treatment under the supervision of medical professionals can help inmates achieve and maintain sobriety in a healthy and safe way. Furthermore, cognitive behavioral therapy can help to identify triggers and teach healthier coping mechanisms to prepare for stressors outside of jail. Finally, multimodal empowerment programs can connect people to jobs, education, and support upon release. People often leave prisons and jail without a sense of purpose, which can lead to relapse and reincarceration. Structured programs have been shown to decrease drug use and criminal behavior by helping reintegrate productive individuals into society.[42] V. Medical Education: Narcotic Treatment Programs and Suboxone Clinics Another proactive approach could be to have medical residency programs register with the Drug Enforcement Administration (DEA) as Narcotic Treatment Programs and incorporate suboxone clinics into their education and rotations. Rather than family medicine, OB/GYN, or emergency medicine healthcare workers having to refer their patients to an addiction specialist, they could treat patients with methadone for maintenance or detoxification where they would deliver their baby. Not only would this educate and prepare the future generation of physicians to handle the opioid crisis, but it would allow pregnant women to develop strong patient-physician relationships. CONCLUSION Society needs to change from the mindset of tackling a problem after it occurs to taking a proactive approach by addressing upstream factors, thereby preventing those problems from occurring in the first place. Emphasizing public health measures and adequate medical care can prevent complications and developmental issues in newborns and pregnant women with substance use disorders. Decriminalizing drug use and encouraging good health habits during pregnancy is essential, as is access to prenatal care, especially for lower socioeconomic patients. Many of the current laws and regulations that policy makers initially created due to naïve political opinion and unfounded bias to serve the War on Drugs need to be changed to provide these opportunities. To progress as a society, physicians and interprofessional teams must work together to truly understand the needs of patients with substance use disorders and provide support from prenatal to postnatal care. There should be advocation for legislative change, not by providing an opinion but by highlighting the facts and conclusions of scientific studies grounded in scientific evidence, health, security, and human rights. There can be no significant change if society continues to view those with substance use disorders as underserving of care. Only when the perspective shifts to compassion can these mothers and children receive adequate care that rehabilitates and supports their future and empowers them to raise their children. - [1] NIDA. 2023, February 15. Pregnant People with Substance Use Disorders Need Treatment, Not Criminalization. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization [2] Substance Use Disorder Hurts Moms and Babies. National Partnership for Women and Families. June 2021 [3] All stories have been fictionalized and anonymized. [4] A History of the Drug War. Drug Policy Alliance. https://drugpolicy.org/issues/brief-history-drug-war [5] The Harrison Narcotic Act (1914) https://www.druglibrary.org/Schaffer/library/studies/cu/cu8.html [6] The War on Drugs. The Global Commission on Drug Policy. Published June 2011. https://www.globalcommissionondrugs.org/reports/the-war-on-drugs [7] Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: A systematic review. Int J Drug Policy. 2011;22(2):87-94. doi:10.1016/j.drugpo.2011.02.002 [8] Global Commission on Drug Policy, 2011 [9] Women NA for P. Tennessee’s Fetal Assault Law: Understanding its impact on marginalized women - New York. Pregnancy Justice. Published December 14, 2020. https://www.pregnancyjusticeus.org/tennessees-fetal-assault-law-understanding-its-impact-on-marginalized-women/ [10] Roberts SCM, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues Off Publ Jacobs Inst Womens Health. 2010;20(3):193-200. doi:10.1016/j.whi.2010.02.003 [11] Klaman SL, Isaacs K, Leopold A, et al. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017;11(3):178-190. doi:10.1097/ADM.0000000000000308 [12] Substance Abuse Reporting and Pregnancy: The Role of the Obstetrician–Gynecologist. https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist [13] R. Ghertner, G Lincoln The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. ASPE. Office of Assistant Secretary for Planning and Evaluation. DHHS Revised September 11, 2018 https://aspe.hhs.gov/reports/economic-opportunity-opioid-crisis-geographic-economic-trends [14] Midon, M. Z., Gerzon, L. R., & de Almeida, C. S. (2021). Crack and motor development of babies living in an assistance shelter. ABCS Health Sciences, 46, e021215-e021215. And for example, see Crack Babies: Twenty Years Later : NPR https://www.npr.org/templates/story/story.php?storyId=126478643 [15] Williams JF, Smith VC, the Committee on Substance Abuse. Fetal Alcohol Spectrum Disorders. Pediatrics. 2015;136(5):e20153113. doi:10.1542/peds.2015-3113 [16] CDC Tobacco Free. Smoking During Pregnancy. Centers for Disease Control and Prevention. Published April 11, 2022. https://www.cdc.gov/tobacco/basic_information/health_effects/pregnancy/index.htm [17] Abuse NI on D. What are the risks of methamphetamine misuse during pregnancy? National Institute on Drug Abuse. https://nida.nih.gov/publications/research-reports/methamphetamine/what-are-risks-methamphetamine-misuse-during-pregnancy [18] CDC. Basics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. Published July 21, 2021. https://www.cdc.gov/pregnancy/opioids/basics.html [19] Honein MA, Boyle C, Redfield RR. Public Health Surveillance of Prenatal Opioid Exposure in Mothers and Infants. Pediatrics. 2019;143(3):e20183801. doi:10.1542/peds.2018-3801 [20] Winkelman TNA, Villapiano N, Kozhimannil KB, Davis MM, Patrick SW. Incidence and Costs of Neonatal Abstinence Syndrome Among Infants with Medicaid: 2004–2014. Pediatrics. 2018;141(4):e20173520. doi:10.1542/peds.2017-3520 [21] Strahan AE, Guy GP Jr, Bohm M, Frey M, Ko JY. Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016. JAMA Pediatr. 2020;174(2):200-202. doi:10.1001/jamapediatrics.2019.4791 [22] Ghose R, Forati AM, Mantsch JR. Impact of the COVID-19 Pandemic on Opioid Overdose Deaths: a Spatiotemporal Analysis. J Urban Health Bull N Y Acad Med. 2022;99(2):316-327. doi:10.1007/s11524-022-00610-0 [23] Mayes LC, Granger RH, Bornstein MH, Zuckerman B. The Problem of Prenatal Cocaine Exposure: A Rush to Judgment. JAMA. 1992;267(3):406-408. doi:10.1001/jama.1992.03480030084043 [24] NICHD Neonatal Research Network. The Maternal Lifestyle Study. clinicaltrials.gov; 2016. https://clinicaltrials.gov/ct2/show/study/NCT00059540 [25] Lester BM, Tronick EZ, LaGasse L, et al. The maternal lifestyle study: effects of substance exposure during pregnancy on neurodevelopmental outcome in 1-month-old infants. Pediatrics. 2002;110(6):1182-1192. doi:10.1542/peds.110.6.1182 [26] Lester BM, Lagasse L, Seifer R, et al. The Maternal Lifestyle Study (MLS): effects of prenatal cocaine and/or opiate exposure on auditory brain response at one month. J Pediatr. 2003;142(3):279-285. doi:10.1067/mpd.2003.112 [27] Bada HS, Bann CM, Bauer CR, et al. Preadolescent behavior problems after prenatal cocaine exposure: Relationship between teacher and caretaker ratings (Maternal Lifestyle Study). Neurotoxicol Teratol. 2011;33(1):78-87. doi:10.1016/j.ntt.2010.06.005 [28] N, P, R. Crack Babies: Twenty Years Later. NPR. Published May 3, 2010. https://www.npr.org/templates/story/story.php?storyId=126478643 [29] Miranda L, Dixon V, September CRP on, 30, 2015. How States Handle Drug Use During Pregnancy http://projects.propublica.org/graphics/maternity-drug-policies-by-state [30] NCDAS: Substance Abuse and Addiction Statistics [2023]. NCDAS. https://drugabusestatistics.org/ [31] (Tenn. Code Ann. § 39-15-216). [32] Institute G. Interactive Map: US Abortion Policies and Access After Roe. https://states.guttmacher.org/policies/ [33] Whitesell M, Bachand A, Peel J, Brown M. Familial, Social, and Individual Factors Contributing to Risk for Adolescent Substance Use. J Addict. 2013;2013:579310. doi:10.1155/2013/579310 [34] CDC. Five Great Benefits of Breastfeeding. Centers for Disease Control and Prevention. Published July 27, 2021. https://www.cdc.gov/nccdphp/dnpao/features/breastfeeding-benefits/index.html [35] Welle-Strand GK, Skurtveit S, Jansson LM, Bakstad B, Bjarkø L, Ravndal E. Breastfeeding reduces the need for withdrawal treatment in opioid-exposed infants. Acta Paediatr. 2013;102(11):1060-1066. doi:10.1111/apa.12378 [36] Ilett KF, Hackett LP, Gower S, Doherty DA, Hamilton D, Bartu AE. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med Off J Acad Breastfeed Med. 2012;7:269-274. doi:10.1089/bfm.2011.0096 [37] Pedersen CA, Smedley KL, Leserman J, et al. Intranasal Oxytocin Blocks Alcohol Withdrawal in Human Subjects. Alcohol Clin Exp Res. 2013;37(3):484-489. doi:10.1111/j.1530-0277.2012.01958.x [38] Montana SB0289. https://leg.mt.gov/bills/2019/billhtml/SB0289.htm [39] Mullins N, Galvin SL, Ramage M, Gannon M, Lorenz K, Sager B, Coulson CC. Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med. 2020 May/Jun;14(3):185-192. doi: 10.1097/ADM.0000000000000562. PMID: 31567599. [40] Drug Related Crime Statistics [2023]: Offenses Involving Drug Use. NCDAS. https://drugabusestatistics.org/drug-related-crime-statistics/ [41] Association APH. Online only: Report finds most U.S. inmates suffer from substance abuse or addiction. Nations Health. 2010;40(3):E11-E11. [42] Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) | NIDA Archives. Published January 17, 2018. http://archives.nida.nih.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition

An invaluable resource for readers interested in architecture and design that demonstrates how the construction, form, and function of key structures in the 19th-century influenced American social, political, economic, and intellectual life. America has always been a nation of thinkers, believers, creators, and builders. Evidence of this is plentiful among the landmarks constructed in the 19th century. Buildings and Landmarks of 19th-Century America: American Society Revealed examines many examples that include homes, office buildings, recreational spaces, military sites, religious buildings, and other landmarks in a variety of geographical locations, discussing the background, architecture, and cultural significance of each. Each engaging, accessible entry not only provides readers detailed information about how the landmark relates to what was going on in American society at the time of its construction but also sparks the reader's interest to research the subject further. As examples, consider that a rural cemetery built in Massachusetts in the early 19th century was the prime influence on public park design and led to the construction of New York's Central Park and many other public parks since. The millionaire industrialist and philanthropist Andrew Carnegie built many of the first free public libraries in the country, which led to the development of municipal public library systems. The huge success of 19th-century world's fairs, like the 1876 Centennial Exhibition and the 1893 World's Columbian Exhibition, had lasting effects on society through the many new products that they introduced to the public. Throughout the book, landmarks are analyzed to elucidate their influence on many aspects of 19th-century society, including the treatment of the mentally ill, impact of religious revivals, growth of leisure and vacation time, and housing for the poor and the western homesteader, among many others. In the "How to Evaluate Buildings and Structures" section, readers are prompted to consider questions such as "What specific purposes did the building or structure have?" "When was it constructed, and what were the circumstances?" and "What was the need it addressed?" Students will learn about the period while also developing the skills of observation and assessment needed to analyze these landmarks and draw meaningful conclusions from them about their context and significance. The discussion of each landmark serves to help readers with these elements of critical thinking, assessment, and analysis.