Death with dignity, physician hastened death, physician-assisted dying, and physician aid-in-dying are all interchangeable terms used to describe a system designed to help terminally ill patients who wish to hasten their death. Within certain areas in the United States mentally competent terminally ill adults can make the decision to end their own life on their own time. To qualify for this law some basic requirements must be met, however different states may have additional requirements. Some basic requirements that are constant in all states are residency, being deemed mentally competent, confirmed terminal illness, and the ability of the patient to administer the medication without any assistance.
To participate in the program a patient must be a resident in one of the following areas: Colorado, D.C., Hawaii, Montana, Vermont, Washington, or California. Terminal illness must be accompanied by a prognosis of six months or less to live and must be verified by two physicians. In states with aid-in-dying laws cooperation by physicians is not mandated. Mid-level providers such as Physician Assistants or Nurse Practitioners are not permitted to prescribe medication to hasten death. Confirmation of terminal illness, prognosis of six months or less to live, and verification of a patient meeting all requirements of the law must be verified by two physicians, even psychiatrists may provide verification.
Patients who qualify under the statue in designated areas are prescribed a medication, usually a large dose of barbiturates, to be taken at a time of their choice. Aid-in-dying laws do not mandate which medication is prescribed to hasten death but is usually a barbiturate or a similar drug compound. A barbiturate is a highly addictive lethal sedative.
Barbiturates were once commonly used to treat a range of ailments such as anxiety and seizures disorders. Barbiturates declined in popularity for prescribers because of their highly addictive nature, lethal overdose potential, and the propensity within the society to abuse the drug. Barbiturates have also been used to carry out capital punishment sentences. The fact this drug has been used to carry out executions has caused controversies with suppliers of the drug. This has led to an exponential increase in the cost of barbiturates. Suppliers of barbiturates are commonly located outside of the United States and may be morally juxtaposed to capital punishment. To thwart the use of their drugs in carrying out capital punishment sentences they have raised the cost of barbiturates thousands of dollars.
The price hike of barbiturates has motivated physicians in the United States to formulate an alternative compound with a similar effect. These alternative compounds have reduced the cost of medication from $25,000 to $400- $600. Barbiturates fall under Schedule 2 controlled substances and are heavily regulated by federal laws. Insurance providers may cover cost of aid-in-dying medications at their own discretion. Use of state insurance cannot be used to pay for medications to hasten death. In most states both physicians and pharmacists are required to report prescribing and dispensing these medications. According to deathwithdignity.
org, “One in three people who obtain medication under aid-in-dying laws choose not to take them”. If any of these medications go unused they must be disposed of in accordance with the law. If an aid-in-dying patient is also a hospice patient, then it is the responsibility of hospice to educate the family of the patient about medication disposal.
The responsibility of medication disposal typically falls upon those present at the time of the patient’s death. States with aid-in-dying laws reported little to no misuse of the medications prescribed. The deathwithdignity.org website says, “There have been no reported cases of misuse of the medications during the 20 years Oregon’s law has been in effect nor the 10 years in Washington and the five years in Vermont.”.
It is an illegal punishable crime to misuse medications prescribed to hasten death. In states without aid-in-dying laws options to hasten death are more limited. Options include but are not limited to withdraw of care, VSED, and palliative sedation. VSED is stands for voluntary stop eating and drinking. VSED is when a mentally competent patient can refuse food, tube feedings, drinks, and fluids.
Palliative sedation is when a patient is medically sedated to live the remainder of their live free of pain. Under aid-in-dying laws a patient’s death is never considered to be a suicide. Their death is always attributed to their underlying illness on their death certificates. Actions have been taken to overturn these laws various times, including an attempt to hold physicians legally responsible for prescribing medications to hasten a patient’s death. The United States Supreme Court eventually ruled that aid-in-dying laws are a decision of the state and not the federal government. The option to hasten death is never forced on patients. Waiting periods between all requests are required.
The ability to withdraw participation at any time is possible. Aid-in-dying laws are imperative to give the terminally ill, who may have anxieties, additional options for their plan of care. These laws also give the terminally ill an option to plan their death as they see appropriate. The aid-in-dying laws got their start in Oregon as early as the 1980s. In the late 1980s the first aid-in-dying bill was introduced.
The first aid-in-dying bill was not passed until 1994. Oregon was the first in the United States to pass such a law. The passage of this first law was met with many obstacles. These obstacles resulted in a three-year delay in implementation of the law.
In 1995 a judge ruled for a permanent injunction on the aid-in-dying law in Oregon. The judge ruled for this injunction claiming that the law was unconstitutional. In 1997 after countless challenges to the aid-in-dying law the case went before the United States Supreme Court. The U.S. Supreme Court ruled in favor of Oregon. An attempt to repeal Oregon’s aid-in-dying law was posed shortly after this ruling; the repeal failed by a large margin. According to deathwithdignity.
org, “80% of Oregonians support the death with dignity law”. In 1997 the potential for penalizing prescribers for their participation becomes a possibility. In 2001 the U.S. Attorney General gave permission for prescribers to be investigated and possibly prosecuted for their participation with aid-in-dying laws. In 2006 this case, Gonzales v Oregon, was heard before the United States Supreme Court. The U.S.
Supreme Court ruled that the federal government was overstepping, and power was once again placed into the hands of the state. According to Oregon.org 1,545 prescriptions have been given and 991 deaths have been hastened since the implementation of the law. Patient demographics were released by Oregon.org showing the typical aid-in-dying patient is either male or female, 65 years of age or older, white and college educated. The survey population cited the common reasons for hastening death are loss of autonomy, loss of dignity, loss of bodily functions, and being a burden on family and caregivers. Per deathwithdignity.org most of the terminally ill patients who utilize the law have cancer.
If physicians suspect a patient may have a mental illness such as depression, they are referred to have a psychiatric evaluation. The need for a psychiatrist referral is minimal. A diagnosis of mental illness would prevent a patient from participating in the program.
The District of Columbia has had an aid-in-dying law implemented since 2017. The District of Columbia has additional patient safeguards in place such as two physician verifications of mental capacity, and a physician verification that the patient is not being coerced into deciding to hasten their death. Physicians in D.C.
must give patients an opportunity to withdraw their request before prescribing a medication to hasten death. In D.C. a prescription for life ending medication isn’t given directly to the patient. The medication will be dispensed by the prescribing physician or a pharmacist. Patients are legally allowed to consume their life ending medication wherever they choose, except in a public place or where they do not have permission to do so.
Many recommendations are given to potential participants on the D.C. government website such as carrying a DNR (Do Not Resuscitate) order and alerting proper medical services prior to ingesting the medication. In D.C.
an aid-in dying death is not considered a suicide and use of life ending medication will not be listed on the death certificate. In D.C.
forgery to obtain a prescription, destroying a request, or coercion can result in felonious charges. D.C. has a relatively new aid-in-dying law and as a result it was hard to obtain any data regarding deaths that can be attributed to the law. Regardless of the region where the law is in effect it still shrouded in controversy.
Some physicians reject this law because they believe it violates the Hippocratic oath they swore to uphold. Organizations such as the American Medical Association have spoken out against the laws but have since neutralized their views. Some believe aid-in-dying laws discriminate against the disabled. Concerns arise from possible pressure a patient may feel from loved ones to end their life and reduce the emotional, physical, and financial burden. While others argue that since the medication is not given by a health care professional it is difficult to articulate who is administering the medication to the patient.
Some churches and some of the public believe is it morally wrong to take one’s life, even if the law doesn’t consider their death a suicide. Others believe that mental health screenings are not vigorous enough and that if enough patients were treated for their mental health issues they wouldn’t participate in the aid-in-dying programs. A common argument against aid-in-dying laws is that the statue is a “slippery slope”. In regions of the world aid-in-dying has been considered for patients suffering from mental illness. Medical aid-in-dying is not a new concept and has been in practice in other countries for many years. Medical assistance to hasten death is a relatively new movement in America.
Seven out of every ten Americans support a terminally ill patients right to end their suffering via aid-in-dying laws (Mataconis, 2015). ?