On June 12th Maine became the 9th state to legalize physician-assisted suicide* (the 8th through legislation). The District of Columbia also allows medically-assisted death; at least 18 states considered or attempted similar laws (so far) this year.
This number represents a small percentage of states, but a significant advancement for a legal right that was first created in Oregon in 1994, then lay (for the most part) dormant in the remainder of the country for the past 25 years. Why is it growing now?
What is physician-assisted suicide, and what does it require? How often is it used?
I would like to give you some answers.
The Beginnings: Oregon in 1994 and Again in 1997
“Death With Dignity” began as a citizen’s initiative in 1994, with 51.31% of Oregonians approving the law in a state-wide vote.
Immediately the law was in trouble. Legal challenges in State Court continued until 1997 when the “Oregon Repeal of Death with Dignity” failed “by a larger margin than the margin by which (the original law) passed, 59.91% to 40.09%.” [quote]
In the meantime, the Federal Government was also upset (the drugs used are subject to federal control under the Controlled Substance Act (CSA) and the Drug Enforcement Administration (DEA). Attorney General John Ashcroft (President George W Bush, 1st Administration) was particularly riled by the Oregon law, but his attempts to defeat it failed. (See Want to Know More, below)
How Many People Have Died in Oregon?
Oregon’s law went into effect in October 1997. The first person who went through with that option was in 1998. Since that time, 2,216 people (data from February 2019) have received medications for suicide- of those 1,459 (65.8%) took them and died as a result.
Maybe having possession of the drugs, knowing that the choice was literally in their hands, was enough for the remaining 34.2% of patients that asked.
The Oregon Death with Dignity law has resulted on average (by my calculations) in 70 deaths a year.
How Do Physician-Assisted Suicide Laws Work?
Death with dignity allows people who have a terminal illness “to voluntarily request and receive a prescription medication to hasten their inevitable, imminent death.” [quote]
All of the laws passed since 1998 mirror the original Oregon law, and include extensive procedures and protections.
A brief review of common questions and the related criteria should help to dispel misunderstandings about what happens in Physician-Assisted Suicide (PAS):
- Can anyone who wants to die get PAS? No: you need to have a terminal diagnosis with a 6-month prognosis confirmed by two licensed physicians
- Are people moving into the state to die? No. You need to be a resident for at least 6 months before seeking medication for PAS
- Are families giving their infirm relatives these drugs? No. the person must be capable of taking the drugs themselves, without assistance. People who are too feeble to do so don’t qualify
- Can someone get PAS medications for someone else? No. Patients must make the request orally, in person, two times (at least 15 days apart). The oral request must be documented and witnessed by two people (not family and not employees of the doctor)
- Are people who want PAS just depressed? No. Patients asking for PAS must be mentally competent and screened for depression by a psychiatrist or psychologist if there is any question about their mental state
- Does PAS happen in the doctor’s office? No. The patient picks up the medication at the pharmacy 48 hours after the completed consent process (i.e., 17 or more days after the initial request)
- What if the patient changes their mind? The process stops immediately (remember also the 34.2% of people who received PAS medications and died without them)
- Does this happen out in the open? Yes. The State tracks and reports these Physician-Assisted Suicides. Violations of any component of the law may result in criminal or civil charges against the physician
- Can a patient demand PAS from their doctor? No. Participation in PAS is voluntary, physicians cannot be forced to assist in their patient’s suicide
Other State Laws (and D.C.)
The Oregon law was a hard-fought battle. It came into effect in 1998, but the significant (fascinating!) federal/state jurisdictional questions it raised were not resolved until the U.S. Supreme Court ruled in Oregon’s favor in 2006. (see Want to Know More, below)
Washington state passed their PAS law as soon as the Supreme Court verified it was a state right; the Montana Supreme Court ruled in favor of PAS the next year (2009)- there is no PAS statute in Montana.
Four years passed before Vermont joined in 2013, California followed in 2015 (although it has had significant challenges).
Both D.C. and Colorado passed their PAS laws in 2016. Hawaii in 2018 and both New Jersey and Maine in 2019 bring us to our current number of ten jurisdictions.
But 2019 is a banner year for PAS across the country.
PAS failed in Arkansas this year and was tabled in New Mexico, was proposed legislation in Virginia in January, is currently getting a hearing in Connecticut, was voted on favorably by the Maryland House of Delegates, is under review by a Nevada Senate Committee, and has the Governor’s support in New York. According to the AP, there are another 11 states where PAS legislation is at least a conversation.
Why Now?
Good Question. I can only offer my guesses.
The Affordable Care Act (“Obamacare”) and the debate before, during, and since has brought healthcare into everyday conversations to a degree most of us have not experienced before. Is the option of PAS an extension of that broader discussion?
Speaking of the ACA- how about the increased cost to patients in the last decade? High-Deductible health insurance plans, although not mandated by Obamacare, certainly became endemic on the law’s coattails. Are people more interested in PAS now because of the high cost of end-of-life care? (Kaiser calculated in 2016 that Medicare spending in the last year of life represented 25% of the total cost for beneficiaries age 65 or older.) Do people want to hasten the inevitable with an eye to their finances?
All that may be true- but my best guess is the sudden growth in PAS has more to do with cultural changes around transparency and control.
As a society, we are demanding more personal management of- and access to- multiple areas of life; banking, education, investment; and accessing news to name just a few.
Controlling how and when we die seems a logical last step in today’s world.
In Closing
I have purposefully not addressed concerns, and opinions for and against Physician-Assisted suicide; on both sides, the arguments are serious, legitimate, and firmly held.
What I think is more important is how you feel about Physician-Assisted suicide. Is this something that may be of interest to you in the future? Then watch for- advocate for- developments in your state. It appears that “Death with Dignity” may become an option for you- regardless of where you live.
Is Physician-Assisted suicide something that repels you? Remember it is a choice, not a requirement, and be sure your absolute refusal is well known to your loved ones and recorded in your Advanced Directive and other end-of-life planning documents.
As is so often true in health care- there is no right answer here other than what you want. My goal is to be sure you are thinking about this important choice now- even if it is still hypothetical– not when it is too late.
* “Physician-Assisted Suicide” was the name initially used to describe the Oregon law in the press- I am dating myself by using it. More current names for these laws include “Medically-Assisted Suicide,” “Death with Dignity.” “Physician Aid-in-Dying,” “End-of-Life Options”, or Vermont’s “Patient Choice and Control at the End of Life Act.”
Want to Know More?
- There is extensive information about these laws, your rights as a patient, the status of legislation in each state, (and more) at the organization Death with Dignity’s website: https://www.deathwithdignity.
org/ - The history of the Oregon Death with Dignity Act was fascinating to watch at the time- especially because Attorney General John Ashcroft (President George W Bush, 1st Administration) became apoplectic every time he talked about the law on camera (alas- I can’t find a clip). Ashcroft’s efforts included the failed “Ashcroft Directive” (which made “prescribing, dispensing, or administering federally controlled substances to assist suicide a violation of the CSA”) and a subsequent suit by Ashcroft against Oregon that led to the U.S. Supreme Court and a win for Oregon (6-3 opinion). The court ruled that Ashcroft “overstepped his authority in seeking to punish doctors who prescribed drugs to help terminally ill patients end their lives.” [Gonzales v. Oregon, 546 U.S. 243 (2006)]