D.C. news media coverage of the district’s Death With Dignity Act

Abstract

In 2016, the District of Columbia City Council passed the Death With Dignity Act. Afterward, Congress attempted to block its implementation by first invoking Congress’s power to overturn the law and then, when unsuccessful in that effort, withhold money from the District. Previous studies examining local news media coverage of aid-in-dying legislation have identified several recurrent frames. D.C. news publications invoked those frames as well as others more specific to the District. Understanding how aid in dying and related legislation is portrayed in newspaper coverage is important as more jurisdictions consider legalization of the practice.

Keywords

aid in dying District of Columbia journalism framing quantitative analysis

In 2016, Mary Cheh (D), a Council member of the District of Columbia (hereafter DC), introduced a medical aid-in-dying bill. The bill received an initial hearing in the health committee, which passed it to the full Council for consideration. The measure passed in two separate votes in November 2016 by a margin of 11-2 each time, ensuring Mayor Muriel Bowser would neither need to affirm nor could veto the bill. Although DC’s council had passed the measure, the U.S. House Oversight Committee attempted to block DC’s new law through its oversight capability (Jamison & Davis, 2017). When Congress failed to act within the set time period, Rep. Andy Harris (R-Maryland) led attempts to block the law through the House Appropriations Committee by refusing to approve the District’s budget (Portnoy & Jamison, 2017), despite declarations from DC’s mayor Muriel Bowser (D) that the District would use no local or federal dollars to implement the law (Nirappil, 2017). Ultimately, the law took effect in 2017.

Examining how writers frame aid in dying can show how journalism and framing are affected by culture and hegemonic beliefs. As they emphasize and deemphasize particular frames associated with the aid-in-dying movement and legislation, journalists, editors, and other writers have a great deal of power to affect how people will perceive and integrate aid-in-dying and related laws into their existing schemata (Neuman, Just, & Crigler, 1992; Tuchman, 1978). Thus, it is important to identify frames in news media about aid-in-dying legislation, such as DC’s Death With Dignity bill, because news media frames act as “prepackaged social constructions” (Gillespie, Richards, Givens, & Smith, 2013, p. 225).

We examine how DC news media, including the Washington Post’s print and online editions, Washington Times, Washington Informer, Catholic Standard, and Washington Jewish Week framed the legislation, including attempts by Congress to nullify it. (According to the Washington Post’s 2017 media kit, the paper’s daily print circulation was 359,158 while its Sunday print circulation was 551,360; the average issue readership in the Washington Metro Market was 992,727 daily and 1,352,905 Sunday [“General Ad Rates,” 2017]. As of September 27, 2017, the Washington Post had more than 1 million paid digital subscribers [Fletcher, 2017]).

Newspapers in the nation’s capital cover not just prominent local topics but also national issues. (This is true even of the Washington Blade, Washington’s premier, and the nation’s oldest, LGBTQ newspaper.) Furthermore, the Washington Post does not produce a “national” edition, unlike the New York Times and Wall Street Journal, which are also considered agenda setters and/or opinion leaders. We performed a content analysis on 115 items—all content related to the legislation in the above-mentioned news outlets—comprising news and opinion. While many framing studies limit the scope to news or editorial content, the nature of this legislation—reflecting and conflicting with cultural beliefs—demands an examination of journalistically produced content such as news and editorials as well as publicly contributed content such as op-eds and letters to the editor.

This study is important for many reasons, many of which are peculiar to American culture. They include an increasing population of aging Baby Boomers, the advancement of medical treatments that prolong the quantity of life, and American cultural disdain for death (e.g., Kadlec, 2013; Samuel, 2013). Several religious traditions (e.g., Childress, 1982; Greenberg, 1997), disability advocacy groups (Not Dead Yet, 2018; Ogunyipe, 2017), and prominent medical organizations (American Medical Association, 2018) oppose euthanasia and medically assisted death. However, state medical associations in California (2015), Colorado (2016), and Vermont (2017), as well as national groups such as the American Academy of Hospice and Palliative Medicine (2016), the American College of Legal Medicine (2008), the American Medical Student Association (2017), and the American Public Health Association (2008) have all recognized a patient’s autonomy to make health care decisions, including those that might lead to death. Dickinson, Clark, Winslow, and Marples (2005) found 14% to 66% of physicians have favored legalizing physician-assisted death over the years, and a 2016 Medscape survey found 57% of U.S. doctors favored medical aid in dying, an increase from 46% in 2010 (Bailey, 2018). While many religions oppose aid in dying, polls have shown both Protestants (58%) and Catholics (55%) support the practice (DiCamillo, 2015). And, although opinion polls show up to 74% of Americans support medical aid in dying (e.g., Jones & Saad, 2013; McCarthy, 2014; Thompson, 2014; Wood & McCarthy, 2017), the continued existence of legal prohibitions against aid in dying in all but six states at the time of this study (“State-by-State Guide to Physician-Assisted Suicide,” 2017) suggests a conflict between public opinion and public law.

Literature Review

The 2014 death of 29-year-old Brittany Maynard, a Californian who moved to Oregon in 2014 to use medical aid in dying, inspired a burst of legislative activity in many states. Oregon was the first state where voters legalized medically assisted death in 1994; it was followed by Washington (2008) and Colorado (2016). Lawmakers in Vermont (2013) and California (2015) passed legislation allowing the practice. Montana’s supreme court, in Baxter v. Montana (2009), asserted nothing in state law precluded medically assisted death for a competent, terminally ill individual. Although a state district court decision legalized physician-assisted death in New Mexico in 2014, a state supreme court overturned that decision, making medically assisted death illegal in New Mexico. Therefore, six U.S. states had legalized medically assisted death prior to or concurrent with the District’s efforts. (Hawaii’s legislature passed a law in 2018 that became effective January 2019.)

Medical aid in dying has been covered by a variety of news media for decades under a variety of names, including physician-assisted suicide, assisted suicide, death with dignity, and the right to die. News media coverage of aid in dying increased toward the end of the 20th century as other rights of privacy and self-determination were recognized, such as birth control, abortion, and same-sex marriage. From the 1980s to the early 2000s, national and local news media primarily focused on the rights of family members (Karen Ann Quinlan and Nancy Cruzan), the actions of practitioners (Timothy Quill and Jack Kevorkian), who is most qualified to judge an uncommunicative person’s wishes (Terri Schiavo), and the jurisdiction (federal or state) holding legal sway over the determination of a right to die. News media coverage of aid in dying surged again in 2014, when Maynard, who had been diagnosed with terminal brain cancer, moved from California to Oregon, one of four U.S. states that had legal aid in dying, so she could determine when and how she would die (Egan, 2014). The right-to-die advocacy group Compassion & Choices helped Maynard publicize her choice through selected national news media, including People magazine, and her widower and mother continued to advocate for options in end-of-life care after Maynard’s death (D. Diaz, personal communication, November 30, 2017).

In the rest of the United States, advance care directives, living wills, and health care power of attorney documents can spell out measures that should be taken to prolong life or hasten death if a patient is unable to communicate his or her wishes. However, a 2009 Pew report found while 35% of Americans believe these documents are important, only 27% to 29% have signed them; furthermore, older Americans are more likely to put medical wishes in writing, and 54% have living wills (Pew Research Center, 2009). Of nearly 8,000 people surveyed in 2009 and 2010, only 26.3% had an advance directive; those who did tended to be older, have a higher socioeconomic status, be more educated, and report having a chronic disease (Rao, Anderson, Lin, & Laux, 2014).

Washington, D.C.’s Unique Nature

Although Washington, D.C., is not a state, it does have powers of self-government as provided in the District of Columbia Self-Government and Governmental Reorganization Act (Public Law 93-198), which Congress passed in December 1973. Its powers include the ability to have a representative government in the form of a City Council and a mayor. However, laws passed by the Council face limitations imposed by the U.S. Congress, including potential nullification of passed laws within a specified time period and regulatory checks over the city’s budget. While Congress has generally taken a hands-off approach regarding nullification, it has often attempted to shape the District through its budgetary control. For example, conservative Republicans had previously targeted other progressive District proposals that legalized same-sex marriage and marijuana (Schwartzman, 2017). In addition, the District is different from all other jurisdictions that have legalized medical aid in dying (as of December 2016) in that it has a majority minority population while the other jurisdictions remain majority White, non-Hispanic (see Table 1). This is important because Black and African Americans and Hispanics/Latinos have been less likely than Whites to support medical aid in dying (Watson, 2016). Black and African Americans also are more likely to mistrust the health care system because historically they have been subject to unethical medical experimentation (Tuskegee syphilis study) and deprived of adequate health care because of socioeconomic status (see, for example, Centers for Disease Control and Prevention, 2005; Elk, 2016; Grann, 2010; Martin et al., 2010).

Table 1

Race/Ethnicity Distribution by State (%)

	CA	CO	MT	OR	VT	WA	DC	US
White non-Hispanic	37.7	68.6	86.5	76.4	93.1	69.5	36.4	61.3
Hispanic or Latino	38.9	21.3	3.6	12.6	1.9	12.5	10.9	17.8
Black/African American	6.5	4.5	0.6	2.1	1.3	4.1	47.7	13.3

Source: U.S. Census Bureau (2017).

Framing Research

Framing provides both a theoretical construct and a method of analysis for researchers. While the theoretical construct has been put forth as a second level of agenda setting (e.g., McCombs, Shaw, & Weaver, 1997), others see it as a theoretical approach to the study of media effects (see, for example, Cacciatore, Scheufele, & Iyengar, 2016; Carter, 2013; Chong & Druckman, 2004, 2007; Johnson-Cartee, 2005; Scheufele, 1999). Framing also draws upon the cultural tradition of hegemony, which contends journalists construct stories—and thus reality (Berger & Luckmann, 1966)—in ways that evoke particular images and references for their readers (Goffman, 1974), most often those that maintain dominant ideological beliefs (Gitlin, 1980), such as valuing and preserving life, protecting vulnerable groups, and recognizing personal autonomy (Glick & Hutchinson, 1999; Strate, Zalman, & Hunter, 2005).

Framing asserts that as an occurrence is transformed into a publicly discussable event, particular characteristics, structural, and textual elements are emphasized and deemphasized, thereby shaping public understanding of and opinions about the occurrence (e.g., Entman, 1991; Gitlin, 1980; Pan & Kosicki, 1993; Scheufele, 1999; Tuchman, 1978). Framing also focuses on structural elements of text, including rhetorical elements such as words, tone, symbols, sources, figurative language, themes, and visual images (Entman, 1991; Gamson, Croteau, Hoynes, & Sasson, 1992; Goffman, 1974; Pan & Kosicki, 1993). Perlman (2013) also identifies the use of quotation marks to suggest the indicated phrase contains sarcasm, irony, or a euphemism. Framing often reflects established hegemonic values (Gans, 1979; Gitlin, 1980). For Gitlin (1980), the meaning of these textual elements, not necessarily the intent of the communicator, lies at the crux of framing concerns. Gamson (1989) suggests that a journalist’s intent can be consciously or unconsciously manifest, and Tuchman (1978) asserts that journalists have “more power than most to construct social reality” (p. 208).

The words used in surveys and news media coverage are important. Medically assisted suicide is the preferred term according to the Associated Press (Hoppin, 2015). However, use of the term “suicide” implies a criminal act and is frowned upon by psychology experts as well as individuals who elect aid in dying. Maynard wrote in an op-ed on CNN.com: “I am not suicidal. If I were, I would have consumed that medication long ago. I do not want to die. But I am dying. And I want to die on my own terms” (Maynard, 2014). Compassion and Choices as well as other right-to-die advocates’ preferred terms include death with dignity, physician-assisted death or physician-assisted dying, aid in dying, physician aid in dying, or medical aid in dying (“Terminology,” 2018). In addition, headlines are the first piece of information a reader sees and a primary entry point into news content; thus, they may impact how readers remember and perceive the information within the article (Ecker, Lewandowsky, Chang, & Pillai, 2014). Language and word choice are important in news media coverage of social issues and legislation because the words, images, ideas, themes, and values that are associated with the aid-in-dying movement will affect how people will perceive and integrate aid-in-dying into their existing schemata (Neuman et al., 1992; Tuchman, 1978).

Beyond language, the sources journalists use to frame stories about controversial issues are an important aspect of framing. These sources have also been called stakeholders and claimsmakers (Miller & Riechert, 2003) and can be public or private. They include “individuals, informal groups, or organized interest groups” (Miller & Riechert, 2003, p. 110), and they use journalists to communicate “preferred meanings” (D’Angelo, 2010, p. 363). In Wiggins’s (2001) study of letters to the editor regarding gay marriage, letter writers engaged in public discourse using the language of journalists and stakeholders that resonated with and reflected ideological beliefs. In their examination of framing of medical news, Briggs and Hallin (2016) found reporters tended to focus on experts and specialists—mostly doctors and researchers—as well as public relations practitioners and activists because they were perceived as having the most knowledge and/or experience. Members of community groups and governmental officials also were used as sources, particularly if a medical issue involved policy (Briggs & Hallin, 2016). Patients were less often used, but when they were, it was to provide human interest (Briggs & Hallin, 2016).

Controversial policy issues are often presented in news as episodic “debates” with two or more sides to maintain a facade of objectivity. While Reese (2001) argues that reducing frames to positions on issues minimizes their impact as organizing structures, Wiggins (2001) suggests that frames can be reduced to thematically oriented stances. Examining issues in episodic and individual, rather than contextualized, points of view influences the way people understand and attribute responsibility for those issues (Pan & Kosicki, 1993; Shah, Domke, & Wackman, 2001) as well as the opinions they form regarding those issues (D’Angelo et al., 2019). For example, news framing may cause readers to be more or less likely to hold public officials accountable, while other frames can spur emotional responses that may strengthen or weaken the valence of one’s opinion (Iyengar, 1996; Lecheler, Bos, & Vliegenthart, 2015). Furthermore, episodic coverage focuses on events while thematic coverage delves more deeply into the context surrounding issues raised by events (Johnson-Cartee, 2005). When health is the topic, episodic framing that uses personalization as a primary tactic results in readers holding individuals accountable while thematic coverage using rhetoric focusing on social bases for the issue results in readers holding government accountable (Kim, Kumanyika, Shive, Igweatu, & Kim, 2010).

Researchers using framing as a theoretical paradigm and/or methodological approach have used both quantitative and qualitative methods to identify cultural themes, stereotypes, and archetypes (Van Gorp, 2010), as well as myths (Lule, 2001). Framing has been used to analyze coverage of political news (e.g., Carter, 2013; Entman, 1991; Gamson & Modigliani, 1989; Gitlin, 1980; Iyengar, 1996), health news (e.g., Park & Bryan, 2010; Weberling, 2012), activist groups (e.g., Ashley & Olson, 1998; Reber & Berger, 2005), and death (Kitch & Hume, 2008) among many other topics. Euthanasia, assisted suicide, and medical aid in dying also have been examined using framing analysis, finding that the practices and their practitioners are often covered negatively (Atwood-Gailey, 1999; Bishop, 2006; Kalwinsky, 1998). D’Angelo et al. (2019) note that integration of theoretical and methodological approaches may be necessary to “understand context-based communication within the public sphere” (p. 3). In addition, Carragee and Roefs (2004) have called for examination of “how power shapes the framing process” (p. 215), and Vliegenthart and van Zoonen (2011) assert “social and cultural contexts” (p. 112) affect media framing.

Therefore, the research questions this study attempted to answer were:

RQ1:What frames do DC newspapers use most often in covering DC’s Death With Dignity Act?

RQ2:How does the type of item affect the frames used?

RQ3:What kinds of sources are used in framing DC’s Death With Dignity Act?

RQ4:What additional frames were used in the coverage of DC’s Death With Dignity Act?

Method

Items for analysis included news stories, feature stories, editorials, op-ed columns, letters to the editor, and news briefs. The researchers collected the items using Nexis Uni and NewsBank databases. While database-based identification of news media content does not include all publications, locates anywhere from 58% to 67% of items from print editions (most often missing briefs and wire service stories), introduces duplicates from multiple editions, and fails to include meaningful data about pagination, design, and photography, using news databases is a feasible way for researchers not from a particular geographic area to identify published content (Ridout, Fowler, and Searles (2012). According to Ridout et al. (2012), acknowledging such limitations while carefully crafting search terms, and using multiple databases for framing studies can help contextualize findings. We limited the database search geographically to Washington, D.C., newspapers as we were focusing on district legislation, specified the exact name of the DC legislation (Death with Dignity), and limited the period of publication to January 1, 2015, through December 31, 2017, as this time frame encompassed the introduction of the legislation through its passage and implementation. The 115 items that were found thus comprise as close to a census of DC newspapers’ news and editorial content as possible.

Content analysis is a research method that allows researchers to describe content as well as make inferences about its production and/or consumption (Riffe, Lacy, & Fico, 2015). To do so, one must define the units of analysis, whether those are individual words or entire phrases or frames of coverage (Riffe et al., 2015). For this study, one researcher created a coding sheet with several variables of interest identified in a previous qualitative study of such content (Lauffer & Baker, 2019), including item type, frames of coverage, sources used, headline tone, and overall stance of the item. Frames of coverage included Potential for Abuse (defined as focusing on safeguards or lack of; potential for coercion of elderly, disabled, or ill individuals by greedy family members; insurance company practices of denying life extending treatments in favor of medical aid in dying); Good Death vs. Bad Death (defined as focusing on gruesome details of prolonged illnesses/deaths versus quick, painless, peaceful alternative of medical aid in dying); Dignity vs. Hope (focusing on the loss of dignity—autonomy, ability to care for oneself, quality of life— as well as false hope offered by extended treatments rather than acceptance of impending death); Hospice Alternative (the use of compassionate care such as hospice or palliative care to mitigate/minimize symptoms as death nears); Slippery Slope (a philosophical argument that if medical aid in dying is permitted for one group of people to choose, it will be applied to others who may not be able to choose—including the elderly, people with severe disabilities, or those with progressive illnesses such as Parkinson’s or ALS); Preserving Rights (focuses on individual autonomy, privacy rights and civil rights as well as the “inalienable right to liberty/happiness”); Culture War (emphasizing the conflict between conservatives/liberals, religious belief and sacrilege, and the right to life versus the right to die); and Brittany’s Legacy (explicitly refers to Maynard’s story and her desire to legitimize medical aid in dying as a health care right). Sources used to advance each frame included health care professionals (doctors, nurses, specialists), legislators (elected or appointed officials), aid-in-dying advocates (those who favor aid in dying and are associated with Compassion and Choices, Dan Diaz, Brittany Maynard, Barbara Coombs Lee, etc.), patients (anyone with a terminal or debilitating illness who seeks palliative, hospice, life-extending, or end-of-life care), religious officials (includes pastors, priests, bishops, Pope, people in charge of religious groups or organizations), family members (family members of patients not including Dan Diaz or Maynard’s mother), opponents of aid in dying (includes disability advocates, those affiliated with political organizations like Focus on the Family, etc.), and other.

The researchers drafted a coding sheet and guidelines using the above definitions and examples to ensure the coders were using the same definitions to extract data from the items. Three coders coded 20 articles (approximately half from Nexis Uni and half from NewsBank) and then held a conference call to verify understanding and application of frames and sources. After this conference call, the investigators coded another 19 items, which were used to calculate intercoder reliability for each frame, headline stance, and overall stance using Krippendorff’s alpha (Krippendorff, 2012). The primary investigator then coded all 76 remaining items while each of the other investigators was assigned approximately 37 additional items to code; thus, all items were double coded.

Reliability tests like Krippendorff’s alpha assess the accuracy of measurement. The variables with the lowest agreement were two frames (Preserving Rights and Culture War), while acceptable levels of agreement were found for the remaining variables (See Table 2). Part of the reason for the low agreement for these two frames may have been multiple interpretations of “rights” and “culture war.” In particular, in addition to patients and family members asserting rights over their own bodies and autonomy over when, where, and how they would die of a terminal illness, the majority-Democratic DC Council and residents asserted rights to self-government without the interference of Congress, particularly conservative Republicans.

Table 2

Intercoder Reliability for Frame, Headline Tone, Overall Stance (n = 19)

Variable	Description	Krippendorff’s α
Frame 1	Potential for Abuse	0.83
Frame 2	Good Death vs. Bad Death	0.79
Frame 3	Dignity vs. Hope	1.00
Frame 4	Hospice Alternative	1.00
Frame 5	Slippery Slope	0.78
Frame 6	Preserving Rights	0.69
Frame 7	Culture War	0.59
Frame 8	Brittany’s Legacy	1.00
Headline tone		0.83
Overall stance		0.83

The coders also pulled examples of the frames from the stories, remaining mindful of contextual factors within the stories, to assist in discerning the overall stance of the coverage. Coverage was considered positive if more paragraphs focused on the positive aspects of the law as presented by advocates, legislators, and patients. Negative coverage focused more on the dangers and opponents’ arguments about slippery slopes and the threats to vulnerable populations. Many news items included negative and positive aspects; in these cases, coders counted the number of paragraphs that presented each perspective in each item. If the number of paragraphs was approximately equal for negative and positive, the item was considered balanced or neutral. A preponderance of oppositional information and viewpoints tilted the item toward negative, while a preponderance of supportive information and viewpoints tilted the item toward positive.

Previous qualitative studies on news media coverage of medically assisted death and newspaper coverage of related legislation have identified eight emergent frames of coverage: Potential for Abuse, Good Death vs. Bad Death, Dignity vs. Hope, Hospice Alternative, Slippery Slope, Preserving Rights, Culture War, and Brittany’s Legacy (Lauffer & Baker, 2019). This study quantitatively examined those frames of coverage in DC newspaper coverage of the District’s Right-to-Die law, which the District Council passed in 2016.

Results

Overall, 115 items were coded. The majority appeared in the Washington Post or its online venue, washingtonpost.com (80), while 13 appeared in the Washington Times, 12 in the Catholic Standard, three in the Washington Informer, two in each of Congressional Quarterly HealthBeat and Creators Syndicate, and one each in the Washingtonian and Washington Jewish Week. Most items coded were news stories (54), followed by letters to the editor (21), op-ed columns (16), editorials (15), and feature stories (eight). Only one item did not fall into any of those categories and was a timeline of death with dignity activity in the United States.

An item’s headline tone (negative, neutral, or positive) was not necessarily indicative of the item’s overall stance toward DC’s Death With Dignity Act. The Catholic Standard (12) and Washington Jewish Week (1) were most consistent as all headlines and overall tone were universally negative toward DC’s Death With Dignity Act. While Congressional Quarterly Healthbeat had two negative headlines, both items had an overall neutral stance. Creators Syndicate had one positive and one negative headline but both items were overall negative toward DC’s Death With Dignity Act. Eight of 13 headlines in the Washington Times were negative (one was neutral and three were positive), but most of its stories had an overall neutral stance (six) compared with four negative and three positive. The Washington Post print edition used primarily neutral headlines (21; nine negative and 12 positive), but its coverage was tilted toward the positive, with 28 items having an overall positive tone (12 neutral and 12 negative). A similar trend was seen in the Washington Post online edition, in which more headlines were neutral (10, compared with eight negative and nine positive) but stories were equally likely to be neutral or positive (11 each) rather than negative (seven). Cross tabulations using SPSS showed the differences among the publications were statistically significant in terms of overall stance (χ² = 49.664, df = 16, p = .000) and headline tone (χ² = 41.002, df = 16, p = .001).

To answer RQ1, as explained in the method, we coded eight frames of coverage: Potential for Abuse, Good Death vs. Bad Death, Dignity vs. Hope, Hospice Alternative, Slippery Slope, Preserving Rights, Culture War, and Brittany’s Legacy. Items could utilize multiple frames. Potential for Abuse was used most often and was found in 60% of items while Preserving Rights was next most common in 47% of items. Good Death vs. Bad Death was found in 46% of items, and Culture War in 43%. Brittany’s Legacy was identified in 17% of items and Hospice Alternative in 15%. Slippery Slope was found in 14% of items, while Dignity vs. Hope was used in just 1% of items.

This study found terminology related to medical aid in dying was more negative than positive. One can look just at the headlines—which used terms such as assisted suicide (used 30 times in headlines), assisted death (used four times in headlines), death with dignity (used 19 times in headlines, 12 with single or double quotation marks around the phrase), physician assisted death (used twice in headlines), and physician assisted suicide (used six times in headlines)—to see how the topic was framed negatively by editors, even when item content was positive or neutral. Medically assisted suicide, the preferred term according to the Associated Press (Hoppin, 2015), was never used in headlines; and advocates’ (“Terminology,” 2018) preferred terms—death with dignity, physician-assisted death or physician-assisted dying, aid in dying, physician aid in dying, or medical aid in dying—were used but often with qualifiers. The name of the DC law was the Death With Dignity Act, but some publications’ headlines would use quotation marks around the phrase to suggest sarcasm, irony, or a euphemism. Other headlines emphasized the danger the bill posed to vulnerable groups, with two using the term “vulnerable.” Headlines of editorials and op-eds written by a member of the Catholic Conference focused explicitly on the danger: “Vote for DC assisted suicide is a loss for everyone,” “A false and dangerous compassion,” and “Why physician-assisted suicide is dangerous.” Another headline emphasized the mistrust of the African American population of DC: “Right-to-die law faces skepticism in nation’s capital: It’s really aimed at old black people.”

To answer RQ2, we see that overall, 33.3% negative items, 28.9% neutral or objective items, and 37.7% positive items toward the legalization of medical aid in dying in DC were published between January 1, 2015, and December 31, 2017. Letters to the editor (71.4%) and editorials (73.3%) were more likely to be positive toward legalization of medical aid in dying than were news and feature stories or op-ed columns. Features were next with 42.9% positive followed by op-ed (25%) and news (18.5%). Op-ed columns were the most negative at 62.5%. Features (42.9%) were the next likely to be negative followed by news (35.2%). Letters (19.0%) and editorials (13.3%) were the least negative. News stories were substantially more neutral (46.3%). All other categories were below 15% (See Table 3). Cross tabulations in SPSS showed editorials and letters were the most positive, op-ed columns were the most negative, and news stories were more likely to be neutral (χ² = 38.883, df = 10, p < .000).

Table 3

Stance Percentage by Type of Item (n = 113)

Type of story	Negative	Neutral	Positive
News	35.3	46.3	18.5
Feature	42.9	14.3	42.9
Editorial	13.3	13.3	73.3
Op Ed Column	62.5	12.5	25.0
Letter	19.0	9.5	71.4
All items	33.3	28.9	37.7

To answer RQ3 regarding sources, the most common frame, Potential for Abuse, used health care professionals as sources 18 times. Legislators were used 23 times; advocates of medical aid in dying were used three times; patients were used seven times; religious officials 17 times; families zero times; and opponents 26 times; many of those opponents were African Americans citing historical data. Other sources included a National Football League (NFL) player with amyotrophic lateral sclerosis (ALS). The next most frequent frame, Preserving Rights, used health care professionals nine times, legislators 27 times, advocates 18 times, patients 11 times, religious officials twice, families six times, opponents four times, and other sources (including polls and lesbian, gay, bisexual, and transgender [LGBT] activists) 20 times. The good death vs. bad death frame’s sources included health care professionals (nine times), legislators (14 times), advocates (nine times), patients (15 times), religious officials (two times), families (nine times), and other sources 11 times. At no time were opponents used as sources for this frame. Brittany’s Legacy frame was advanced through legislators (six times), advocates (five times), patients twice, families (10 times), opponents once, and other sources (eight times). Health care professionals and religious officials were never used for this frame. The Hospice Alternative frame relied primarily on health care professionals (eight times) and other sources (five times, including data from Oregon, research studies, and a professor). Patients were used four times, legislators once, religious officials twice, and opponents three times. The Slippery Slope frame used health care professionals once, legislators three times, advocates three times, religious officials five times, families once, opponents seven times, and other sources, including now-Supreme Court justice Neil Gorsuch, three times. The Culture War frame was sourced by health care professionals (10 times), legislators (39 times), advocates (23 times), patients (four times), religious officials (16 times), families—including NPR’s Diane Rehm—(six times), opponents (17 times), and other—including polls, Gorsuch, and African American activists (27 times). The least most common frame, Dignity vs. Hope, used only two kinds of sources once each: patients and families.

To answer RQ4 about other frames, the researchers coded Frame 9: Other (Identify). Fifty-two items (45.2%) did not have an “other” frame. Of those that did, the most common frame (24%) focused on Congressional oversight of the District that emphasized the body’s budgetary role or perceptions of oversight overreach. Twenty percent focused on DC’s autonomy as a legislative jurisdiction. Nine percent focused on the religious concept of sanctity of life and God’s role in giving and taking life from humans. In addition, 4% focused on the (changing) role of physicians and their oath to “do no harm”; 2% primarily focused on race and specifically equated the practice of medical aid in dying to racist or eugenic targeting of Blacks, and 2% focused on the lack of appropriate palliative care. Legislators were most often the source for the frames of Congressional oversight (used 27 times) and DC autonomy (used 23 times), while religious officials were most often sources for sanctity of life/man-made in God’s image (used 11 times). Health care professionals were sources for the do-no-harm clause of the Hippocratic Oath (used 5 times).

Discussion and Limitations

The prevalence of the Potential for Abuse frame suggests either that this is one issue about which the public is most concerned, or that this is an issue that the news media have chosen to highlight more than others because of the inherent news value in this particular theme—potential for abuse stirs emotion, sparks fear, and captures the interest of news audiences. We are concerned that so few items were found in coverage of this social issue and legislation: only 115 appeared over the 2-year time period studied despite examining coverage from in the Washington Post and its online venue, washingtonpost.com, Washington Times, Catholic Standard, Washington Informer, Congressional Quarterly HealthBeat, Creators Syndicate, Washingtonian, and Washington Jewish Week. Because we used electronic databases to identify items, we may have missed some items published in print editions; however, using databases is a feasible way for researchers not from a particular geographic area to identify published content. Therefore, we carefully crafted our search terms, used multiple databases, and contextualized our findings.

The District’s jurisdictional characteristics were an unexpected confounding factor in this study. Prior research has focused on legislation regarding medically assisted death in states, all of whom have complete jurisdiction (barring an infringement on Constitutional rights). The District has powers of self-government limited by Congressional oversight and budgetary approbation. The House Oversight Committee, initially led by Rep. Jason Chaffetz (R-Utah), attempted to block the law through its oversight capability (Jamison & Davis, 2017). When Congress failed to act within the set time period, Rep. Andy Harris (R-Maryland) tried to use the House Appropriations Committee to disapprove the District’s budget (Portnoy & Jamison, 2017), despite declarations from DC’s mayor Muriel Bowser (D) that the District would use no local or federal dollars to implement the law (Nirappil, 2017). Most stories focusing on federal oversight made no claims about the statute but focused on Congressional overreach and oversight as the problem. This might suggest DC newspapers are more concerned about DC’s autonomy, which faces encroachment by the federal government, and implies that the legislation may not be a pressing concern; it also suggests a partisan divide evident throughout the United States but of particular importance in DC. Furthermore, future studies on framing of public policy in local newspapers might be improved by focusing more how framing is affected by media ecology, sourcing, and audience perceptions of policy issues.

Conclusion

The current study expands framing theory by examining the role of power and culture in framing of medical aid in dying. It is consistent with other framing scholarship on health issues, which have shown coverage is both personalized and episodic. Furthermore, it examines not just news and editorial content produced by journalists but also contributions by members of the public in the form of op-eds and letters to the editor.

The focus on individual experiences with death (Good Death vs. Bad Death) demonstrates that personal responsibility and individual accountability position aid-in-dying as a civil right (Preserving Rights) and frame it in an episodic manner. In this study, normative journalistic framing strategies emphasize preservation of rights and personal autonomy, reinforcing these cultural beliefs. As a second-level agenda setting construct, journalists prime aid in dying as a personal issue rather than a much larger social concern. Further research to determine why negatively framed op-eds about medically assisted death are published more frequently than negatively framed editorials is important. For example, are negative op-eds published to approximate a sense of balance in coverage of this topic? Are they used to marginalize cultural beliefs journalists may not hold? Political elites, policy makers, and politicians can see that focusing on individual narratives to show positive and negative implications of aid in dying is an effective strategy for framing public policy debates.

While frames in health news are often thematic, focusing accountability on social institutions, we found journalists used physicians to highlight that doing harm is wrong and often used negative terms such as suicide in this line of argument. Socially, death is taboo and coverage of aid in dying emphasizes this socially constructed forbidden narrative, particularly in news items. Perhaps American readers and journalists are not yet comfortable thinking about death, especially by choice, as that is far from a “normal” cultural convention. Potential for abuse ties into this—the most frequent negative frame showed opponents are concerned about hypothetical problems—so even the major arguments against aid in dying tend to shy away from discussion about actual people, demonstrating the reluctance to discuss actual death and focus on pretend death. Physicians and medical institutions should pay attention to the implications of thematic versus episodic framing of aid in dying. The news accentuates individuals over ideals, which may affect the practice of medicine. “Do no harm” is no longer accepted at face value but questioned by patients, families, and physicians. Is a prolonged and painful death no harm compared with a quick, likely painless, assisted death? Medical norms and values are shifting, as evident in officially neutral positions taken by medical advocacy organizations; how are they reflecting and influencing journalistic coverage and public policy?

It is not unusual to find more frames emphasizing conflict than frames promoting agreement; after all, conflict is a known element of newsworthiness. What is interesting, though, is that the types of conflict presented in items about medically assisted death and legislation to legalize the practice rely on long-held, deep-seated beliefs and are often based in religious doctrine and cultural experience. In particular, Black and African Americans in DC expressed concern about this law because of their cultural experience of health care disparities and unethical medical experimentation. Other oppositional coverage relied on the religious belief of the sanctity of life and God’s power to take or give it. That aid-in-dying laws were passed (by ballot or legislative action) in six U.S. jurisdictions by the end of 2017—and public opinion polls demonstrate general support for the practice—shows deepening rifts in the country between beliefs and practices, conservatives and liberals, church doctrines and practitioners’ desires, majority culture and minority culture, medicine and health. Further academic research and self-reflection on the part of news and editorial staffs in regard to the impact of these rifts on news and editorial coverage of aid in dying is necessary as politicians, legislatures, and voters continue to consider these laws.

Footnotes

ORCID iD

Kimberly A. Lauffer

References

American Academy of Hospice and Palliative Medicine. (2016). Statement on physician-assisted death. Retrieved from http://aahpm.org/positions/pad

American College of Legal Medicine. (2008). ACLM policy on aid in dying. Retrieved from http://c.ymcdn.com/sites/www.aclm.org/resource/collection/11da4cff-c8bc-4334-90b0-2abbe5748d08/Policy_On_Aid_In_Dying.pdf?hhSearchTerms=“assisted+and+death”

American Medical Association. (2018). Physician-assisted suicide—Code of medical ethics opinion 5.7. Retrieved from https://www.ama-assn.org/delivering-care/physician-assisted-suicide

American Medical Student Association. (2017). Principles regarding physician aid in dying. In AMSA preamble, purposes and principles (pp. 78-79). Retrieved from https://www.amsa.org/wp-content/uploads/2017/07/2017-PPP.pdf

American Public Health Association. (2008, October 28). Patients’ rights to self-determination at the end of life (Policy Statement 20086). Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/13/28/patients-rights-to-self-determination-at-the-end-of-life

Ashley

Olson

(1998). Constructing reality: Print media’s framing of the women’s movement, 1966 to 1986. Journalism & Mass Communication Quarterly, 75, 263-277.

Atwood-Gailey

(1999). Constructing a “good death”: News media framing of the euthanasia debate from 1975 to 1997 (Unpublished doctoral dissertation). The University of Tennessee, Knoxville.

Bailey

(2018, January 28). As more docs support medical aid in dying, advocates look to legalize physician assisted death. Physicians News Digest. Retrieved from https://physiciansnews.com/2018/01/28/medical-aid-in-dying-legalize-physician-assisted-death/

Baxter v. Montana. (2009). 224 P.3d 1211, 2009 MT 449, 354 Mont. 234, 2009 Mont. LEXIS 695 (Mont. Dec. 31, 2009).

10.

Berger

P. L.

Luckmann

(1966). The social construction of reality: A treatise in the sociology of knowledge. New York, NY: Penguin Books.

11.

Bishop

J. P.

(2006). Framing euthanasia. Journal of Medical Ethics, 32, 225-228. doi:10.1136/jme.2005.013847

12.

Briggs

C. L.

Hallin

D. C.

(2016). Making health public: How news coverage is remaking media, medicine, and contemporary life. New York, NY: Routledge.

13.

Cacciatore

M. A.

Scheufele

D. A.

Iyengar

(2016). The end of framing as we know it . . . And the future of media effects. Mass Communication and Society, 19, 7-23.

14.

Carragee

Roefs

(2004). The neglect of power in recent framing research. Journal of Communication, 54, 214-233.

15.

Carter

M. J.

(2013). The hermeneutics of frames and framing: An examination of the media’s construction of reality. SAGE Open, 3, 1-12. doi:10.1177/2158244013487915

16.

Centers for Disease Control and Prevention. (2005). Health disparities experienced by Black or African Americans—United States. Morbidity and Mortality Weekly Report, 54, 1-3.

17.

Childress

J. F.

(1982). Who should decide? Paternalism in health care. New York, NY: Oxford University Press.

18.

Chong

Druckman

J. N.

(2004). A theory of framing and opinion formation in competitive elite environments. Journal of Communication, 57, 99-118. doi:10.1111/j.1460-2466.2006.00331

19.

Chong

Druckman

J. N.

(2007). Framing theory. Annual Review of Political Science, 10, 103-126. doi:10.1146/annurev.polisci.10.072805.103054

20.

D’Angelo

(2010). Conclusion: Arriving at the horizons of news framing analysis. In D’Angelo

Kuypers

J. A.

(Eds.), Doing news framing analysis: Empirical and theoretical perspectives (pp. 356-368). New York, NY: Routledge.

21.

D’Angelo

Lule

Neuman

W. R.

Rodriguez

Dimitrova

D. V.

Carragee

K. M.

(2019). Invited forum: Beyond framing: A forum for framing researchers. Journalism & Mass Communication Quarterly, 96, 12-30. doi:10.1177/1077699018825004

22.

DiCamillo

(2015, October). Strong voter support for the “End of Life Option Act.” San Francisco, CA: Field Poll, Field Research Corporation.

23.

Dickinson

G. E.

Clark

Winslow

Marples

(2005). U.S. physicians’ attitudes concerning euthanasia and physician-assisted death: A systematic literature review. Mortality, 10, 43-52.

24.

“District of Columbia Self-Government and Governmental Reorganization Act.” (1973). Public Law 93-198, 87 Stat. 774-836.

25.

Ecker

U. K.

Lewandowsky

Chang

E. P.

Pillai

(2014). The effects of subtle misinformation in news headlines. Journal of Experimental Psychology: Applied, 20, 323-335.

26.

Egan

N. W.

(2014, October 27). Ending my life—My way. People Magazine, 82(18), 64-69.

27.

Elk

(2016). The first step is recognizing, acknowledging, and respecting the inequity, disrespect, and disregard our African American patients have experienced. Journal of Palliative Medicine, 19, 124-125.

28.

Entman

R. M.

(1991). Framing U.S. coverage of international news: Contrasts in narratives of the KAL and Iran Air incidents. Journal of Communication, 41(4), 6-27.

29.

Fletcher

(2017, September 27). Washington Post tops 1 million in paid digital subscriptions; LA Times leads regional dailies. Forbes. Retrieved from https://www.forbes.com/sites/paulfletcher/2017/09/28/the-washington-post-tops-one-million-in-paid-digital-subscriptions-la-times-leads-regional-dailies/#20b51e891bac

30.

Gamson

W. A.

(1989). News as framing. American Behavioral Scientist, 33, 157-161.

31.

Gamson

W. A.

Croteau

Hoynes

Sasson

(1992). Media images and the social construction of reality. Annual Review of Sociology, 18, 373-393.

32.

Gamson

W. A.

Modigliani

(1989). Media discourse and public opinion on nuclear power: A constructionist approach. American Journal of Sociology, 95, 1-37.

33.

Gans

H. J.

(1979). Deciding what’s news: A study of CBS Evening News, NBC Nightly News, Newsweek, and Time. New York, NY: Pantheon Books.

34.

General Ad Rates. (2017). Retrieved from https://www.washingtonpost.com/wp-stat/ad/public/static/media_kit/16-2980-01-Gen.pdf

35.

Gillespie

L. K.

Richards

T. N.

Givens

E. M.

Smith

M. D.

(2013). Framing deadly domestic violence: Why the media’s spin matters in newspaper coverage of femicide. Violence Against Women, 19, 222-245.

36.

Gitlin

(1980). The whole world is watching: Mass media in the making and unmaking of the new left. Berkeley: University of California Press.

37.

Glick

H. R.

Hutchinson

(1999). The rising agenda of physician-assisted suicide: Explaining the growth and content of morality policy. Policy Studies Journal, 27, 750-765.

38.

Goffman

(1974). Frame analysis: An essay on the organization of experience. Cambridge, MA: Harvard University Press.

39.

Grann

V. R.

(2010). Erasing barriers to minority participation in cancer research. Journal of Women’s Health, 19, 837-838.

40.

Greenberg

S. I.

(1997). Euthanasia and assisted suicide: Psychosocial issues. Springfield, IL: Charles C Thomas.

41.

Hoppin

(2015, April 6). In end-of-life debate on Sen. Bill Monning’s bill, words matter. Santa Cruz Sentinel. Retrieved from https://www.santacruzsentinel.com/2015/04/06/in-end-of-life-debate-on-sen-bill-monnings-bill-words-matter/

42.

Iyengar

(1996). Framing responsibility for political issues. The ANNALS of the American Academy of Political and Social Science, 546, 59-70.

43.

Jamison

Davis

A. C.

(2017, February 14). A blow to D.C. law on assisted suicide. The Washington Post, p. B05.

44.

Johnson-Cartee

K. S.

(2005). News narratives and news framing: Constructing political reality. Lanham, MD: Rowman & Littlefield.

45.

Jones

Saad

(2013, May). Gallup Poll social series: Values and beliefs. Gallup News Service. Retrieved from https://www.webpages.uidaho.edu/~stevel/251/Belief_in_God_160629.pdf

46.

Kadlec

(2013, August 14). A good death: How Boomers will change the world a final time. Time. Retrieved from http://business.time.com/2013/08/14/a-good-death-how-boomers-will-change-the-world-a-final-time/

47.

Kalwinsky

R. K.

(1998). Framing life and death: Physician-assisted suicide and the New York Times from 1991 to 1996. Journal of Communication Inquiry, 22, 93-112.

48.

Kim

A. E.

Kumanyika

Shive

Igweatu

Kim

(2010). Coverage and framing of racial and ethnic health disparities in U.S. newspapers, 1996-2005. American Journal of Public Health, 100(S1), S224-S231.

49.

Kitch

Hume

(2008). Journalism in a culture of grief. New York, NY: Routledge.

50.

Krippendorff

(2012). Content analysis: An introduction to its methodology. Thousand Oaks, CA: SAGE.

51.

Lauffer

K. A.

Baker

S. D.

(2019). U.S. media coverage of Brittany Maynard’s choice to die: How ideology and framing converged. Atlantic Journal of Communication. Advance online publication. doi:10.1080/15456870.2019.1616739

52.

Lecheler

Bos

Vliegenthart

(2015). The mediating role of emotions: News framing effects on opinions about immigration. Journalism & Mass Communication Quarterly, 92, 812-838.

53.

Lule

(2001). Daily news, eternal stories: The mythological role of journalism. New York, NY: Guilford Press.

54.

Martin

S. S.

Trask

Peterson

Martin

B. C.

Baldwin

Knapp

(2010). Influence of culture and discrimination on care-seeking behavior of elderly African Americans: A qualitative study. Social Work in Public Health, 25, 311-326.

55.

Maynard

(2014, November 2). My right to death with dignity at 29. Retrieved from http://www.cnn.com/2014/10/07/opinion/maynard-assisted-suicide-cancer-dignity/index.html

56.

McCarthy

(2014, June 18). Seven in 10 Americans back euthanasia. Gallup Poll Trends. Retrieved from http://www.gallup.com/poll/171704/seven-americans-back-euthanasia.aspx

57.

McCombs

M. E.

Shaw

D. L.

Weaver

(1997). Communication and democracy: Exploring the intellectual frontiers in agenda-setting theory. Mahwah, NJ: Lawrence Erlbaum.

58.

Miller

M. M.

Riechert

B. P.

(2003). The spiral of opportunity and frame resonance: Mapping the issue cycle in news and public discourse. In Reese

S. D.

Gandy

Grant

A. E.

(Eds.), Framing public life: Perspectives on media and our understanding of the social world (pp. 107-122). Mahwah, NJ: Lawrence Erlbaum.

59.

Neuman

W. R.

Just

M. R.

Crigler

A. N.

(1992). Common knowledge: News and the construction of political meaning. Chicago, IL: The University of Chicago Press.

60.

Nirappil

(2017, May 24). Bowser intent on launching assisted-suicide law despite rule on tax money. The Washington Post, p. B02.

61.

Not Dead Yet. (2018). Retrieved from http://www.notdeadyet.org/

62.

Ogunyipe

B. T.

(2017, September 29). NCD letter to Congressman Wenstrup regarding sense of Congress on assisted suicide. Retrieved from https://www.ncd.gov/publications/2017/ncd-letter-sense-congress-assisted-suicide

63.

Pan

Kosicki

G. M.

(1993). Framing analysis: An approach to news discourse. Political Communication, 10, 55-75.

64.

Park

Bryan

R. H.

(2010). Using public relations to promote health: A framing analysis of public relations strategies among health associations. Journal of Health Communication, 15, 39-54.

65.

Perlman

(2013, January 28). “Scare” tactics. Columbia Journalism Review. Retrieved from https://archives.cjr.org/language_corner/scare_tactics.php

66.

Pew Research Center. (2009, August 20). End-of-life decisions: How Americans cope. Retrieved from http://www.pewsocialtrends.org/2009/08/20/end-of-life-decisions-how-americans-cope/

67.

Portnoy

Jamison

(2017, July 15). House panel moves to revoke D.C.’s suicide law. The Washington Post, p. B04.

68.

Rao

J. K.

Anderson

L. A.

Lin

Laux

J. P.

(2014). Completion of advance directives among U.S. consumers. American Journal of Preventive Medicine, 46, 65-70.

69.

Reber

B. H.

Berger

B. K.

(2005). Framing analysis of activist rhetoric: How the Sierra Club succeeds or fails at creating salient messages. Public Relations Review, 31, 185-195.

70.

Reese

S. D.

(2001). Prologue—Framing public life: A bridging model for media research. In Reese

S. D.

Gandy

Grant

A. E.

(Eds.), Framing public life: Perspectives on media and our understanding of the social world (pp. 7-32). Mahwah, NJ: Lawrence Erlbaum.

71.

Ridout

T. N.

Fowler

E. F.

Searles

(2012). Exploring the validity of electronic newspaper databases. International Journal of Social Research Methodology, 15, 451-466.

72.

Riffe

Lacy

Fico

F. G.

(2015). Analyzing media messages: Using quantitative content analysis in research (2nd ed.). Mahwah, NJ: Lawrence Erlbaum.

73.

Samuel

L. R.

(2013, June 23). Death, American style. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/psychology-yesterday/201306/death-american-style

74.

Scheufele

D. A.

(1999). Framing as a theory of media effects. Journal of Communication, 49, 103-122.

75.

Schwartzman

(2017, February 13). Chaffetz unfazed by detractors in Utah and the District. The Washington Post, p. A01.

76.

Shah

D. V.

Domke

Wackman

D. B.

(2001). The effects of value-framing on political judgment and reasoning. In Reese

S. D.

Gandy

Grant

A. E.

(Eds.), Framing public life: Perspectives on media and our understanding of the social world (pp. 227-243). Mahwah, NJ: Lawrence Erlbaum.

77.

State-by-state guide to physician-assisted suicide. (2017, February 21). ProCon. Retrieved from https://euthanasia.procon.org/view.resource.php?resourceID=000132

78.

Strate

J. M.

Zalman

Hunter

D. J.

(2005). Physician-assisted suicide and the politics of problem definition. Mortality, 10, 23-41.

79.

Terminology. (2018). Death with Dignity. Retrieved from https://www.deathwithdignity.org/terminology/

80.

Thompson

(2014, December 5). Most Americans agree with right-to-die movement. HealthDay/Harris Poll. Retrieved from https://consumer.healthday.com/mental-health-information-25/behavior-health-news-56/most-americans-agree-with-right-to-die-movement-694268.html

81.

Tuchman

(1978). Making news: A study in the construction of reality. New York, NY: Free Press.

82.

U.S. Census Bureau. (2017). QuickFacts. Retrieved from https://www.census.gov/quickfacts/

83.

Van Gorp

. (2010). Strategies to take subjectivity out of framing analysis. In D’Angelo

Kuypers

J. A.

(Eds.), Doing news framing analysis: Empirical and theoretical perspectives (pp. 84-109). New York, NY: Routledge.

84.

Vliegenthart

van Zoonen

(2011). Power to the frame: Bringing sociology back to frame analysis. European Journal of Communication, 26, 101-115.

85.

Watson

(2016, June 8). California aid-in-dying law concerns some Latinos, blacks. Associated Press. Retrieved from https://apnews.com/a0a60c4fb44544d394944fe68b2e338a

86.

Weberling

(2012). Framing breast cancer: Building an agenda through online advocacy and fundraising. Public Relations Review, 38, 108-115.

87.

Wiggins

E. L.

(2001). Frames of conviction: The intersection of social frameworks and standards of appraisal in letters to the editor regarding a lesbian commitment ceremony. In Reese

Gandy

Grant

A. E.

(Eds.), Framing public life: Perspectives on media and our understanding of the social world (pp. 207-214). Mahwah, NJ: Lawrence Erlbaum.

88.

Wood

McCarthy

(2017, June 12). Majority of Americans remain supportive of euthanasia. Gallup News. Retrieved from http://news.gallup.com/poll/211928/majority-americans-remain-supportive-euthanasia.aspx