Tuesday, 18 December 2012

Liverpool Care Pathway - The Misperceptions Of Disability

“The parents want “nothing done” because they feel that these anomalies are not consistent with a basic human experience.” “The basic human experience” is undefined, but left only to mean that the parents deem a life with this disability to be a life that is not worth living. The doctor continues, “In a soft voice the father begins to tell me about their life, their other children, and their dashed hopes for this child. He speculates that the list of proposed surgeries and treatments are unfair and will leave his baby facing a future too full of uncertainty.”  Read as: if we cannot be certain the child will function as we hoped, we don’t want our lives or our other children to be burdened with a child who may have special needs. Regardless of the intentions of parents, whether it is bigotry against persons with disabilities that manifests into a genuine misperception that a child is better off dead- or simply selfishness in demanding nothing less than a “perfect” child- the anonymous doctor tells us that children who are denied food and water take an average of 10 days to die.
Charlotte Lozier Institute 

Thanks to Harlow Blogger for this article published on VP-NET -

VP-NET Vulnerable Persons and End of Life New Emerging Team

Disability, Constructed Vulnerability, and Socially Conscious Palliative Care

Carol J Gill. Journal of Palliative Care. Toronto: Autumn 2006. Vol. 22, Iss. 3; pg. 183, 8 pgs

Abstract (Summary)
In my work as a disability studies researcher, I am accustomed to excavating the hidden social dynamics of phenomena that seem simply physiological to the average observer. We know that scholars of race and gender have produced a huge body of work to disentangle "biology" from the social determinants of "destiny" for women and people of colour.

Copyright Center for Bioethics, Clinical Research Institute of Montreal Autumn 2006
Because people with disabilities have had to fight tenaciously to counter stereotypes of weakness and incompetence, discussions of our vulnerability feel risky from the outset. One way to offset the damage of conventional thinking about disability and vulnerability is to pursue a more complex understanding grounded in disabled people's experience. Conversations with my fellow members of the disability community over the last few years have taught me a new way to look at vulnerability. I do not take issue with the idea that many people with disabilities are vulnerable, but I am struck by how much that vulnerability is socially constructed rather than inherent in our physical or cognitive conditions.


In my work as a disability studies researcher, I am accustomed to excavating the hidden social dynamics of phenomena that seem simply physiological to the average observer. We know that scholars of race and gender have produced a huge body of work to disentangle "biology" from the social determinants of "destiny" for women and people of colour. In the last two decades, disability studies scholars and disability rights advocates have built upon these efforts to show that disability, too, is a socially constructed category (and a relatively modern one, at that), and that key disadvantages faced by disabled people emanate from social treatment rather than from deficiencies in their constitution (1). This social analysis has been warmly welcomed by people with disabilities, who appreciate how well it documents what they have experienced. To paraphrase a common response, "All my life I've been told that I can't get into my neighbourhood restaurant because my legs won't take me up stairs. Now I know it's because the restaurant owner won't build a ramp." In his classic analysis of society's power to shape and constrain the lives of people who function outside the norm, sociologist Robert A. Scott declared, "Blind men are not born, they are made" (2, p.121). In humble homage to Scott, I assert that disabled people are not innately vulnerable but are made so by a social environment that devalues human difference.

Vulnerability concerns power and lack of power. Many people with long-term impairments confront society's power over their lives each day as they struggle with abridged choices and blocked access to resources. They know that, regardless of their value and competence, they are less likely than nondisabled counterparts to get an adequate education, a job, an organ transplant, a ride to where they need to go, or a date (3). They are more likely to be socially isolated and under the poverty line. These inequities constitute the foundation of disabled people's status as a vulnerable group. People with disabilities may be particularly vulnerable during periods of economic stress. As cost-cutting measures take effect, community values prescribing charitable care of disabled citizens can give way to questions about prudent distribution of resources (4). Although most people with disabilities hate being objects of charity, we realize that we are not likely to fare any better when the discussion moves from charity to measures of social utility!

Vulnerability in the Medical System

Unfortunately, many people with disabilities feel particularly vulnerable in medical settings. Medical classification, emphasizing abnormality and deficiency, permeates the public's understanding of life with disability. Doctors and other Healthcare professionals have served as the primary authorities in public policy affecting us, as well as in our personal life histories. Whether we remember them as kindly paternal or frighteningly austere, medical experts have diagnosed our problems, predicted our potential, and prescribed measures to alter our bodies and our futures. That is a lot of power.

Now, managed care has inserted issues of social utility into this dynamic. Although managed care policies may decentralize some of the authority formerly vested solely in the physician, they have failed to transfer more control to people with disabilities who require substantial assistance to live. In an atmosphere where words like "extraordinary" and even "futile" get attached to the supports we use each day, we feel caught between the power of the medical expert to decide what we need, and the power of the healthcare funding system to judge our needs as excessive. For example, in August 2005, the St. Louis Post-Dispatch reported that Missouri Medicaid would no longer pay for such resources as ventilators, feeding tubes, crutches, and wheelchair batteries needed by an estimated 340,000 adult Missourians with disabilities. These services are deemed "optional" under Medicaid rules, and the Missouri legislature opted to cut them. Although an appeals process existed for disabled citizens to plead their case as "exceptions", the newspaper reported, the state failed to mention this option in letters sent to Medicaid recipients informing them of the cuts.

In this context, disabled people's distrust of the healthcare system has only intensified, impelling them toward hard decisions. Several years ago, I talked with a disabled man who has an important job, many friends, and an impressive list of accomplishments. He told me emphatically that he would never again enter a hospital no matter how critically ill he becomes. I hardly knew how to interpret such a declaration. I found it drastic and disturbing. I wondered if he was severely depressed. Before long, however, I heard other disabled persons take up this theme. Most are individuals commonly described as "severely" disabled. They appear and function in ways judged extraordinary. Some use ventilators and most require technological and human assistance to accomplish the tasks of daily living. In the context of their extensive physical impairments, some observers might read their avoidance of hospitalization as a rational advance directive. But that would be a misinterpretation. Rather than forego life support, they have resolved to protect their lives by bunkering themselves in familiar surroundings until the end. The medical system, they say, is a dangerous place for them.

When I shared these stories with a physician friend, she seemed dispirited. Surely, something could be done and must be done to help these individuals feel supported in medical settings. Her view of hospitals was very different from theirs. She hospitalized her patients to increase their safety, to surround them with care. At that time, I had no reason to take sides in this difference of opinion. My own sense of hospitals was vague because I had had little recent experience of them.

My perceptions have changed dramatically since then. In the last four years, I have been hospitalized twice for respiratory problems and once for surgery. I am still traumatized by those experiences.


As background, I should mention that I contracted polio the year before the Salk vaccine was approved for public distribution. Since then, I have spent most of my life using a wheelchair for mobility and dealing with respiratory problems. Fifteen years ago, I developed severe sleep apnea and began using a positive pressure mechanical ventilator noninvasively via nasal mask each night. Initially, I was hesitant to accept this remedy for my restless nights, shortness of breath, and soaring blood pressure. But I was fortunate. I was in touch with a community of people with neuromuscular disorders. Many used ventilators, some part time and others full time. They were wonderful role models in that they claimed the right to live fully but in nonnormative ways. In fact, they incorporated assistive technology and human assistance into their daily routines so matter-of-factly, so gracefully, that these supports became a "normal," almost trivial, part of their lives. These friends understood that I had been conditioned by popular cultural images to equate ventilator use with dying, suffering, entrapment. The ubiquitous phrase "hooked up to a machine" haunted me. My friends deprogrammed me and helped me view ventilators as the benign, useful devices they are. They gave me information and encouragement. They introduced me to doctors who were familiar with people like us, and the doctors provided additional information and encouragement. Together, this network allowed me to see that, in the greater scheme of things, noninvasive ventilator use is not a big deal. Their reasonable stance saved my life.

A very different reception greeted me when I was hospitalized with my first bout of pneumonia four years ago. Arriving with my own ventilator, I was immediately treated as if I were a hopeless case. Hospital staff came in and out of my room, inspecting my ventilator, sometimes riddling with its controls without explanation and without addressing me personally in any way. One nurse threw back my blanket, lifted my hospital gown, and shouted into the hallway, "Why isn't she catheterized?" Apparently, she thought anyone with limited mobility also had impaired sensation and lack of bladder control, neither of which is true for most people who have had polio. Sometimes, in self-defence, I tried actively to engage staff in conversation, to signal my conscious humanity before they did something demeaning to me. Although this strategy helped in some cases, a few of the conversations that ensued were more unnerving than being ignored. In one instance, a pulmonary specialist seemed startled to find me capable of intelligent conversation. A look of pity swept across his face. He patted my shoulder and said he would do his best to help me get through this, but.... He did not complete the sentence and, by that point, I did not want to hear its conclusion. As it turned out, my chest X-ray and other tests revealed that my condition actually was not critical. The doctor who had been taken off guard by my intelligence was equally surprised by my viability.

Other conversations I had with healthcare professionals during that hospitalization and subsequent ones conveyed their disturbing lack of familiarity with living long-term with extensive impairments, as well as scepticism about the value of such a life. Most expressed surprise that I had a job, let alone a job as a professor who could teach people things. They were also surprised to learn that I lived in my own home, was married, and had young grandchildren. On their own, they could not conceive of my life being ordinary or lived outside of a healthcare facility. As we discussed these facts of my existence, I noticed that theirs eyes would dart to my ventilator and back again repeatedly. They were trying to fit both my physical condition and the fullness of my world into their narrow conception of life with a disability. Most could not reconcile the two domains.

Although my needs for physical assistance in activities of daily living (ADL) sometimes elicited pity and other negative reactions (such as irritation from overworked nursing staff over the extra time it took me to eat, bathe, transfer in and out of bed, and use the bathroom), it was my ventilator that prompted the most comment during my hospitalizations. A sweet young medical resident sympathetically exclaimed that it "must be awful to be dependent on that." I told her, in my best upbeat conversational tone, that, actually, it was not. Rather, it was quite comfortable and helpful, and, furthermore, I did not think of myself as dependent on it but saw myself as simply using it. Her fixed expression told me that this last point about my agency was lost on her. Nor did she seem persuaded that the ventilator was not an instrument of torture. She left my room with her prejudgments intact.

In addition to sympathy, conversations with health professionals about my ventilator revealed a frightening lack of knowledge. Many physicians and nurses thought that my ventilator pumped oxygen into my lungs, when, in fact, it just gives me breaths of room air. Actually, polio specialists have warned me that breathing substantial amounts of oxygen can possibly be dangerous for me, decreasing my respiratory drive. My primary problem is underventilation. If I am adequately ventilated, my oxygen saturations are fine. Yet, during each of my last three hospitalizations, professionals have tried to give me oxygen "to help me out." Some respiratory therapists thought my ventilator was a CPAP device, a machine that uses a constant stream of air to keep breathing passages open. Others thought that my ventilator was set to deliver breaths only when I triggered them by my own breathing. Neither is the case. I have central apnea as well as the obstructive type. To avoid hypoventilation, my ventilator pushes air into my lungs at regular intervals. Although I can breathe well during the day, I let the ventilator breathe for me at night. When I tried to correct misperceptions about my respiratory set-up, some therapists insisted they knew best and argued with me about how my ventilator functioned. One therapist allowed that I might be right about the current set up, but that the ventilator settings should be changed to withhold breaths unless I triggered them first. This therapist's response stands out in my mind because I realized, part way through the conversation, that he was underestimating my respiratory insufficiency because he thought I was too "with it" to need full cycled ventilation. Again, it was difficult for his imagination to encompass both facts at the same time-that I was a fully engaged, competent agent and that I needed to use a ventilator each night to stay alive.


I offer this level of detail about my personal experiences to flesh out what vulnerability means for many people with disabilities in healthcare settings. Several factors construct our vulnerability. One is the "alien" factor. When people with disabilities enter the medical system, we often feel like unexpected aliens whom no one understands. Our efforts to communicate who we are and what we need are unsuccessful, and we experience a disquieting sense of isolation. During all three of my recent hospitalizations, I met only a couple of hospital professionals who had any familiarity with people who live with disability. They were the only ones who seemed to expect me to have a life.

A related factor concerns judgments about quality of life. As medical and public discourse expands about "death with dignity," it seems increasingly permissible to question whether some forms of living are too burdensome, too hopeless, or too unaesthetic to merit support. This rush to judgment about "how awful" it is to have incurable impairments, in a society with decreasing tolerance for human limitations and imperfections in general, sends a message that our lives are untenable. Media stories of nonsentient or suffering people helplessly tethered to tubes and machines are the horror tales of our age. Although no one pities the scuba diver or astronaut who uses a breathing device, ventilators used quite comfortably by people with respiratory insufficiency are viewed as the definitive mark of a subhuman existence. If only Nike or Apple would launch an advertising campaign to rehabilitate that image!

In addition to our alienation and devaluation in medical settings, we are now dealing with managed care fallout. When medical care is rushed and rationed, disabled people become exceedingly inconvenient. We need help, we need equipment, and we need time. It is so much easier to move in and out of our hospital rooms if there is no conversation. It is easier to deal with our daily needs if we can either care for ourselves or stay in bed immobile. It is the in-between nature of disability that is so troublesome. We aren't independent but we aren't passive. We aren't getting well but we aren't getting on with dying. We require engagement; we need assistance and respect at the same time. We are too demanding. From a purely pragmatic standpoint, we don't fit in.

This is not to imply that disabled people are alien, devalued, and resented only in the medical setting. We feel this in the larger world, too, but in healthcare environments, the dynamics intensify. When we seek health services, we enter a highly structured system with established protocols and power hierarchies that can strike vulnerability into the hearts of most consumers. This milieu can be especially daunting for people with disabilities because we have struggled so hard to control our lives despite all the social barriers we encounter. In other words, we have more to lose than most people when we enter dominating systems, especially when those systems are insensitive to our delicately balanced strategies for self-determination. For example, another disabled man I know was forced by hospital staff to stay in bed during mealtimes. Although he could eat on his own when seated at a table, in bed he had no way of positioning his partially paralyzed arm so he could feed himself. When he asked for help, the nursing staff reported that he was becoming more dependent and might need nursing home care. Fortunately, his wife was an occupational therapist and could clearly perceive the cycle of his iatrogenic disempowerment.

Experiences such as these illustrate not only that disabled people may feel vulnerable in medical settings, but that they are vulnerable. This man might have ended up in an institution rather than going home, were it not for the intervention of his wife. I could have had my ventilator wrongly reconfigured by health professionals who did not understand my condition, were it not for my vigilance and ability to argue my case. Those are close calls. It is not much comfort to know that mistakes like this usually flow from the best intentions. They still threaten our bodily and psychological integrity.

Even when the threats are not so concrete, they can be potent. My family and friends know me to be an assertive, even powerful person. I have written and presented work on positive identity for people with disabilities. Moreover, I have conducted research on health professionals' attitudes toward people with disabilities and have offered recommendations to disabled people about how to navigate health systems. Yet, even with all of this fortifying me, I still feel completely demoralized within hours of entering most healthcare environments. The attitudes and actions surrounding me there tell me that I am too disabled to live. Although I feel robust and even fairly healthy around people who are familiar with my way of life, in the hospital I am made to feel fragile, critical.


Against this backdrop, it makes sense that many people with disabilities are leery of endof-life discussions. When I was in training as a clinical psychologist, I was taught that there is a difference between fear and anxiety. Supposedly, fear is based on an identifiable source of perceived danger, whereas anxiety has no clear source and is, therefore, diffuse and difficult to contain. When ethicists and others analyze disabled people's opposition to the right-to-die movement, they seem to reduce that opposition to a matter of anxiety. They recommend working on ways to reassure disabled people, and to build trust between them and their health professionals, as though the problem is a diffuse concern with no direct link to real danger. This analysis fails to acknowledge that disabled people are in fact fearful, not anxious. It glosses over the identifiable threats to our lives that we stare down daily in the medical system and in greater society.

Palliative care specialists who wish to address the needs of people with disabilities at the end of life, can begin by learning more about the socially created hazards of disability that instill realistic fears. There is a disability studies literature and a body of work from the disability rights resistance to "death with dignity" that describes and analyzes the basis of these fears (e.g.,4-10). This information is a primer in cultural competency in disability and should be required reading in health professional training. Unless doctors know more about the social context of our lives, they will not have the necessary tools to decrease our vulnerability and to interpret, in context, the stated end-of-life wishes of their patients with disabilities.


The complexities of this endeavour are undeniable. For example, whom do we include in the category "people with disabilities" when considering end-of-life care? Some right-to-die advocates feel that people who have been disabled most of their lives have little in common with people who acquire disabilities only at the end of life as the result of aging or terminal illness. In fact, some argue that the physical limitations brought on by terminal conditions should not be considered disabilities at all. However, if you understand the social dynamics of disability, the common ground shared by these two groups becomes clearer.

The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits one or more major life activities, such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. This definition applies to many formerly nondisabled people as they reach the end of life. Because of pain, weakness, sensory impairment, coordination problems, and other physical changes associated with terminal illnesses, many dying people will experience the kind of limitations that constitute disability. It is at this point that many will become concerned about needing help and burdening others, social abandonment, lack of access to gratifying activities, loss of important roles and status, and living in an aesthetically unacceptable state. These concerns, grounded in social relations and cultural values, are similar to the concerns of others who acquire disabilities at any point in the lifespan, including the teenage athlete who loses his leg in an accident and feels devoid of value, the young mother who learns she has multiple sclerosis and worries that she will lose her husband and children, and the older man who is diagnosed with progressive blindness and anticipates a life of social and sensory isolation. All must confront both their physical limitations and the negative social responses to those limitations that can turn them into hopeless losses. In fact, many people with disabilities find that, rather than distinguishing disability from terminal conditions, the public often conflates "incurable" and "terminal," associating disability with dying or a fate worse than death. This perception underlies such common public commentary as, "If I were like you (blind, paralyzed, reliant on a wheelchair or ventilator), my life would be over."

There is no denying, however, that despite commonalities across various experiences of disability in our society, including disability caused by terminal illness, there are also qualities that distinguish them. Certainly, when disability is experienced for the first time at the end of life, there is less time to adapt, more concurrent losses to process and, arguably, fewer options to offset limitations than when disability occurs earlier in life. On the other hand, the intensity of interpersonal connection and transformation of values that may emerge in the dying process can contribute significantly to a more positive and meaningful disability experience. The important point is that many of the concerns expressed by individuals at the end of life are disability-related and, like most problems of disability, they have a strong social aspect that can moderate or exacerbate the experience of physiological loss.

In Oregon, terminally ill individuals have requested and received lethal prescriptions to alleviate disability-related concerns. As a disabled person and as a scholar of the social dynamics of disability, I cannot perceive this "treatment" as socially responsible medicine. I am not reassured by arguments regarding the autonomy of those who choose death in these circumstances. Those arguments neglect two important points. First, the devaluing messages that surround people with disabilities-whether terminally ill or not-are coercive. Choosing death in response to social coercion is not an autonomous act. second, autonomy implies choices. Most disabled people, including economically privileged ones, receive little help to envision and secure meaningful options. They rarely learn about available accommodations to help them continue meaningful roles and activities, they do not have examples to show them that personal assistance services and assistive devices can be dignified alternatives, and they do not receive deprogramming to counter their social conditioning about disability. And although assisted suicide law offers them the option of a facilitated death, the law does not guarantee the resources they need to live meaningfully to their last breath. As I have addressed in previous writing (6,11), policies that guarantee choices to die but not choices to live meaningfully increase our vulnerability, not our autonomy.

Palliative care specialists can help their patients address these practical and existential concerns by recognizing them as disability-related concerns. The next step is learning about the options available to address these concerns, because until health professionals know that there are meaningful alternatives, they will not be able to help their patients believe there are alternatives to hastened death. Disability rights advocacy groups can link physicians to a wealth of information to share with patients and their families. Meaningful options increase power and decrease the unnecessary vulnerability that may lead to desperate decisions.

Another complexity that palliative care specialists will confront in working with people with disabilities is the question: when is it appropriate for people with disabilities to receive palliative care services? If people with extensive disabilities are viewed prima facie as suffering and tenuously viable, the next step may be premature withdrawal of measures that extend their lives. Some disability advocates are concerned that palliative care services, such as hospice, may become the new dumping ground for persons with brain injuries, developmental disabilities, high-level quadriplegia, progressive neuromuscular disease, and other supportintensive disabilities. With adequate support, individuals with such conditions can live a long time-too long, in the opinion of a significant sector of the public. Without adequate support; they will die. The idea that such conditions can be framed as terminal or hopeless is ominous. Although many people with disabilities oppose aggressive treatments imposed on them to fix or cure their impairments with little hope of success, most want access to a full array of healthcare options and other supports to enhance and extend their lives. If palliative care becomes associated with a narrowing of those options for people with disabilities, it will increase disabled people's distrust of end-of-life care. More important, such practices will increase disabled people's vulnerability to further devaluation and discriminatory treatment.

One more complexity has to do with the primary focus of palliative care: the alleviation of suffering. Some might say that suffering is a highly personal matter, but in another sense, suffering, like disability, is a highly social matter. The public generally equates disability with suffering. Because I have physical limitations, need help from others, and use devices such as a wheelchair and ventilator, many observers perceive me as a sufferer. I do not draw the same conclusion. Ironically, their prejudgments cause me more suffering than my impairments do. Having suffering incorrectly attributed to us when we are simply living our lives differently is a quintessential disability experience. A related experience is being harmed by people who think they know what we need and are trying to help. Sometimes I think disabled people have been harmed much more by well-intentioned individuals than by malicious ones. Unfortunately, that list may include family members, counsellors, teachers, health professionals, and others in our support system. Even our loved ones often pity and misunderstand disability.

It is important for palliative care specialists to develop sophistication about suffering in the context of disability. This starts by challenging the assumed link between bodily impairment and suffering. After all, disabled people's impairments are rarely curable. If suffering always followed from impairments, disability would be a hopeless state indeed. Despite public opinion to the contrary, however, most people with disabilities report as much satisfaction with life as anyone else (6). When they are dissatisfied, the reasons are often social rather than impairmentrelated. As already suggested, socially induced suffering calls for improvements in social arrangements and relationships.

There is no denying that some impairments cause physical and emotional suffering. Fatigue, pain, weakness, and functional limitation can be intrinsically difficult. These experiences call for compassionate and informed medical care, and this is where palliative care can shine, potentially. However, acknowledging disabled people's right to treatment for impairment-related suffering does not imply that suffering necessarily diminishes the value or quality of one's life. Nor does it imply that remedies for physical suffering must be always medical. People with disabilities often embrace a range of nonmedical modalities, including work, intimacy, activism, expressive arts, and peer support. All available options to improve life should be considered.


It is difficult for most people to believe that life with an extensive disability can be anything but suffering, and that suffering can be anything but dehumanizing. Perhaps, along with tolerance for imperfection, the public spirit has lost some of that down-to-earth courage in the face of human difficulties that carried previous generations through very hard times. I have also noticed how narrow the public imagination has become about what makes life valuable-so unimaginatively narrow that it cannot seem to encompass those two realities-disability and full humanity-simultaneously.

Physicians are members of society who occupy a powerful place in the lives of people with disabilities. Hopefully, they can shed the dangerous misconceptions about disability that permeate society and create disabled people's vulnerability. To address disabled people's suffering in a responsive and responsible manner, palliative care specialists must understand and address the social side of disability. The ideal of palliative care at its life-affirming best has potential for partnership between physicians and people with disabilities who face end-oflife decision making. Perhaps, under the right circumstances, individuals with disabilities, whose conditions have eluded cure, could be well served by physicians for whom cure is not the goal. For this potential to be realized, however, palliative care specialists will need to develop a wide imagination about the fullness of living with disability, and then convey that view to their patients through the end of life.

Date received, April 19, 2006; date accepted, June 29, 2006.

1. Longmore PK. Why I Burned My Book and Other Essays on Disability. Philadelphia, Pennsylvania: Temple University Press, 2003.
2. Scott RA. The Making of Blind Men. New York: Russell Sage Foundation, 1969.
3. Shapiro JP. No Pity: People with Disabilities Forging a New Civil Rights Movement. New York: Three Rivers Press, 1994.
4. Russell M. Beyond Ramps : Disability at the End of the Social Contract. Monroe, Maine: Common Courage Press, 1998.
5. Coleman D. Withdrawing life-sustaining treatment from people with severe disabilities who request it: equal protection considerations. Issues Law Mod 1992; 8(1): 55-79.
6. Gill CJ. (2000). Health professionals, disability, and assisted suicide: an examination of relevant empirical evidence and reply to Batavia (2000). Psychol Public Policy Law 2000; 6: 526-545.
7. Longmore PK, Umansky L. The New Disability History. New York: New York University Press, 2001.
8. Marks D. Disability: Controversial Debates and Psychosocial Perspectives. Oxford: Routledge, 1999.
9. Michalko R. The Difference That Disability Makes. Philadelphia, Pennsylvania: Temple University Press, 2002.
10. Morris J. Pride Against Prejudice: transforming attitudes to disabilities. London: Women's Press, 1998.
11. Gill CJ. The false autonomy of forced choice: rationalizing suicide for persons with disabilities. In: Werth JL (ed). Contemporary Perspectives on Rational Suicide. Series in Death, Dying, and Bereavement. Philadelphia, Pennsylvania: Brunner/Mazel, Inc., 1998; pp. 171-180.

[Author Affiliation]
CAROL J. GILL, Department of Disability and Human Development, University of Illinois at Chicago, Chicago, Illinois, USA

[Author Affiliation]
Gill, Carol J., PHD
Chicago Center for Disability Research
Department of Disability and
Human Development
University of Illinois at Chicago
(MC 626)
1640 West Roosevelt Road, Room 236
Chicago, Illinois
USA 60608

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