Medical Aid in Dying Update

Right-to-die movement looks to California
By Elizabeth Sidney

Numerous polls show growing public support for medical aid in dying. And now that California has joined the tiny handful of states that allow terminally ill adults to request physician-prescribed aid-in-dying, interest groups are watching to see what happens in this testing ground.

The state’s right-to-die law was sparked by the publicized ordeal of Brittany Maynard, a young woman who moved from northern California to Oregon in 2014 so that she could “die legally.” Maynard had been diagnosed with terminal brain cancer. She ended her life on Nov. 1, 2014. Prior to then, she recorded testimony on behalf of right-to-die legislation then being considered in California. The law went into effect last June.

Meanwhile, the California Medical Association (CMA) became the first state medical association to change its stance on physician aid-in-dying. In 2015, the CMA voted to change its decades-old policy on the issue to a neutral position after several committee hearings and an extensive amount of discussion by members.

Judging from Oregon, where aid-in-dying took effect in 1997, California’s new law could result in as many as 1,500 lethal prescriptions written each year, according to Compassion and Choices, a national advocacy group. In 2012, about 115 Oregon residents obtained life-ending drugs, and 77 actually ingested them, according to health department records.

Oregon was the first state to pass an aid-in-dying law, through binding voter referendums. Washington did likewise in 2008, also by referendum. Vermont’s state legislature passed a death-with-dignity statute in 2012. Montana’s aid-in-dying law was legalized by a State Supreme Court decision in 2009.

The Death with Dignity organization spearheaded laws in all four of the states. It also led campaigns in Maine, Hawaii and Massachusetts, which were defeated by narrow margins.

Activity Afoot in Illinois

The dramatic increase in states considering death with dignity laws suggests it’s only a matter of time before Illinois officially considers such a bill. While the political climate in Illinois differs from that of Oregon and California, advocates here have coalesced around the Illinois Patient Choices at End of Life Act. This Oregon-style bill was drafted by the Illinois End of Life Options Coalition.

The bill sets stringent conditions terminally patients must meet before their doctor can prescribe a lethal drug. For instance, physicians are required to explain the alternatives including hospice and palliative care. At every stage doctors must provide the patient with the opportunity to rescind the request. The patient’s physician and a second, consulting physician must agree that the patient is terminally ill–and can be expected to die within six months. Both doctors must agree also that the person is mentally competent and capable of making an informed decision. If either doctor has any doubts, they must refer the patient for a psychiatric evaluation. The process may only proceed if that professional finds the patient mentally competent and capable of making an informed decision. Mental illness does not disqualify a patient, however.

Nothing is done on impulse. Patients must submit separate requests, two orally, and one in writing directly to the physician, and comply with several waiting periods. Once the request is approved, the patient has to self-administer the drug or it is done by another mentally competent adult with the ability to make an informed decision.

The Illinois bill mandates that the death certificate list the patient’s underlying illness as the cause of death, and prohibits any clause in any contract or insurance policy from being conditioned upon or affected by a patient’s taking advantage of or not taking advantage of the legislation. Physicians who follow all the stipulated steps and adhere to the law receive immunity from civil and criminal liability as well as professional disciplinary action.

Additionally, no health provider is obligated to participate. Healthcare facilities that provide notice of their non-participation to their physicians may prohibit any physician from participating in any act on its premises.

The law has several features to ensure that medications are not diverted. Unused medications would be properly disposed of, according to Final Options Illinois.

Finally, participating physicians and pharmacists must keep detailed records, with all activities reported to the Illinois Department of Public Health. The IDPH would be mandated to prepare and publish an annual statistical report, detailing the number of patients going through the process, the percentage who take the prescribed drugs, and the diseases they are suffering from.

The bill states explicitly that patients are “hastening their death,” not “committing suicide.” Nor does the bill use the term “physician-assisted suicide.” While physicians are critical to the process, their involvement is limited to the steps outlined in the bill.

Although public support for aid-in-dying is stronger than ever, a large number of Americans still oppose the practice. Some base their opposition on religious or ethical beliefs, citing the “slippery slope” effect. Opponents worry a law would open the door to coercion by family members, putting pressure on the elderly or disabled to hasten their death. Another concern is that patients may want to die for reasons other than physical pain—loss of autonomy, fear of the unknown, loneliness or financial burden.

Medicine: A House Divided

The American Medical Association opposes aid-in-dying laws. However, a 2014 Medscape survey found that 54% of physicians favor physician-assisted dying, up from 46% in 2010. At its June 2016 annual meeting, the AMA voted to study a resolution on the question of aid-in-dying. Its Council on Ethical and Judicial Affairs will reevaluate current policy.

Right-to-die advocates argue that many physicians who support the option could be reluctant to declare so publicly. Advocates say it is common for physicians to give life-ending medications, and medical aid-in-dying laws would simply codify and bring to light a practice already taking place.