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Dispelling Myths About Death with Dignity in Washington, D.C.

October 26, 2016

The Death with Dignity National Center strongly supports B21-0038, the Death with Dignity Act of 2015, as introduced by D.C. Councilmember Mary Cheh.

Attacks against the bill are based on the personal, religious, or moral objections of opponents, rather than on the decades of available evidence about how Death with Dignity laws have worked in real life.

The bottom line: Death with Dignity laws are carefully crafted to offer the choice to hasten death only to a small number of terminally ill patients who can qualify, and who badly want this option. The proposed District legislation contains multiple safeguards to prevent any person from being coerced to take this option, and allows doctors and pharmacists the right to refuse to participate.

In almost three decades of experience in states where these laws are in place, the concerns raised by opponents—coercion, discrimination—simply have not come to pass. Further, only a relatively small number of terminally ill patients ask for and qualify for these medications. And as many as a third who obtain the medications never use them. But the peace of mind they offer at the end of life is without price.

B21-0038 Protects Terminally Ill District Residents

First, and most importantly, we need not speculate about whether Death with Dignity laws result in family members, physicians, insurance companies or anyone else coercing terminally ill patients to use them. In nearly 30 years of combined experience in Oregon and Washington, there has not been a single demonstrated case of coercion.

Instead, experience has demonstrated that the safeguards in those states’ laws, which are almost identical to the bill proposed in the District, are effective at protecting patients from any form of undue influence.[1] In addition, peer-reviewed research has found no evidence whatsoever of heightened risk to, or, in fact, any instances of abuse of particularly vulnerable groups.[2] Those who oppose this law offer no examples of such coercion—because they cannot.

The proposed District legislation contains multiple safeguards to prevent any person from being coerced to take this option, and allows doctors and pharmacists the right to refuse to participate.

Like assisted dying laws passed by other states, the D.C. bill would protect all terminally ill residents of the District by codifying a rigorous process that patients must follow before they can obtain medication to peacefully hasten their death, regardless of their race, ethnicity or financial circumstances. The law sets forth multiple steps patients must take to qualify, and make it crystal clear that no family member may coerce a terminally ill loved one into using the law.

The array of stringent safeguards in the bill is carefully designed to ensure that the patient is truly the one in control and driving the process. The bill mandates a range of decision points at which patients must make their own choice clear: they must make multiple oral and written requests for the medication; must get a second physician opinion; are urged to notify their families; and must be physically able to administer the medication themselves. As an additional safeguard, the patient is offered multiple opportunities to rescind their request for life-ending medications.

Finally, scientific journal articles have demonstrated that doctors all across the country already dispense life-ending medications at the request of patients or family.[3] By passing this law, the Council will stop the sort of back-hallway prescribing that now happens with a wink and a nod, and shine a bright light on the process.

Death with Dignity Provides Peace of Mind to Terminally Ill Patients

The Death with Dignity Act of 2015 protects the elderly from being coerced into using these medications. By definition, it is almost always the elderly who suffer from terminal diseases. The median age of people accessing the Death with Dignity Act in Oregon is 71.

The national organization that helps terminally ill Americans navigate their end-of-life options, Compassion & Choices, has more than two decades of accomplishment at this delicate task. Their staff and dedicated volunteers have provided assistance to thousands of Americans at the end of life. The organization has consistently operated within the bounds of the law, and there is simply no evidence of their coercing or counseling any individual to use the law. On the contrary, in many cases they have had to direct patients to other end-of-life options when they did not satisfy the stringent criteria to use the Death with Dignity option. It is an affront to dying people everywhere to make baseless accusations against this dedicated group of volunteers and service providers.

Prior to joining our Board of Directors in 2013, our President, George Eighmey, worked as Executive Director of Compassion & Choices’ Oregon chapter for 12 years. In his experience, it was in most cases patients who had to persuade their loved ones to give their blessing to use this option.

Finally, people who have accessed the Oregon law cite decreased ability to engage in the activities that make life enjoyable; loss of autonomy; and loss of dignity as their chief end-of-life concerns. Burdening their family ranks toward the bottom of terminally ill people’s end-of-life concerns.

Death with Dignity Is Just One End-of-Life Option

There have been allegations that insurance companies in Oregon have denied coverage for cancer treatment, and offered Death with Dignity medication instead. That is false.

The sole evidence the law’s opponents offer to support this objection is a letter an insurance company once sent to a patient denying covering for a cancer treatment that was neither demonstrated to be effective, nor approved by the FDA. Notably, opponents have repeatedly refused to produce this letter. Why? Because the letter does not contain an offer to pay for death-hastening medications in lieu of chemotherapy.

The State of Oregon investigated this allegation, and the Governor—a physician himself—found the accusations baseless: “…[S]ome have twisted the story of one woman on the health plan, making the appalling insinuation that services covered under Oregon’s Death with Dignity Act are prioritized over chemotherapy because it costs less for patients to die than to live. Nothing could be further from the truth.”

Governor Kitzhaber concluded, “No treatment has ever been denied because death would be more ‘cost effective.’ The very idea is both abhorrent and a blatant distortion of the facts.”[4]

The Death with Dignity Act Contains Safeguards to Protect Vulnerable Populations

Death with Dignity laws are simple standards of medical practice, with no implied value judgments about patients who do, or do not, choose to use them. The proposed bill, and the Oregon model law, specifically outline who qualifies to obtain the medication: mentally competent adult residents diagnosed with a terminal illness that will lead to death within six months. In other words, the bill does not discriminate on the status of disability (or age or minority status, for that matter) because that status is not a qualifying or otherwise relevant circumstance. And, as already stated, there is simply no evidence for the claim that Death with Dignity legislations has disproportionate impact on patients in vulnerable groups, including people with disabilities.

In fact, people with disabilities often allege that the bill discriminates against them because it puts undue obstacles in their way if they wish to use it, e.g. that they have to take (self-administer) the medication themselves and without assistance. In 2007 testimony before the American Public Health Association, Robert Joondeph, Executive Director of Disability Rights Oregon (DRO), stated that the only complaints his organization had received about the state’s Death with Dignity Act “focused on the concern that the Act might discriminate against persons with disabilities who would seek to make use of the Act but have disabilities which would prevent self-administration, thereby denying these persons the ability to use the Dignity Act.”

Joondeph confirmed that he had “no personal knowledge of cases in Oregon that contradict the findings in” peer-reviewed studies. In addition, DRO had “never received a complaint that a person with disabilities was coerced to make use of the Dignity Act.” In a 2016 update, Joondeph wrote that DRO “has still not received a complaint of exploitation or coercion of an individual with disabilities in the use of Oregon’s Death with Dignity Act.”[5]

B21-0038 Requires Patients to be Mentally Competent

Contrary to the allegations of the law’s detractors, the Death with Dignity Act of 2015 mandates mental health examinations. Both the consulting and the attending physician must examine the patient, and if the patient appears to be suffering from a psychiatric or psychological disorder (including depression) that causes impaired judgement, the patient must be referred for counseling. Furthermore, the proposed bill states that “no covered medication shall be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment,” [Section 5(b)].

All patients seeking to qualify to receive a prescription to hasten death must pass two medical screenings to demonstrate that they have the capacity to make healthcare decisions. There is a higher burden for any person who fails this initial screening process—he or she must be referred for specialist psychological or psychiatric counseling and must be determined to be free of any condition limiting capacity to make healthcare decisions.

The result? All patients receive at least two screenings, and there is an additional screening and treatment for those whose condition raises concerns for the attending or consulting physician. Two or three screenings does not equal zero, as opponents suggest.

If the absence of the word “screening” forms the core of the argument, consider the statement that “Nothing contained in this act shall be interpreted to lower the applicable standard of care for the attending physician, consulting physician, psychiatrist or psychologist, “ [Section 12(f)]. Physicians must follow the standard of care for diagnosing capacity to make healthcare decisions which includes screening tools. Again, the proposed legislation calls for a minimum of two, and perhaps three, mental health screenings.

We are hopeful that, in making a decision that will affect terminally ill constituents, Councilmembers will rely on decades of evidence and the actual text of the proposed law, rather than the wild allegations and myths put forward by its detractors.

References:

[1] Oregon Death with Dignity Act: 2015 Data Summary, Oregon Public Health Division, February 4, 2016, Retrieved from http://www.healthoregon.org/dwd.

[2] Battin et al. “Legal physician-assisted dying in Oregon and the Netherlands: The question of “vulnerable” groups. A reply to I.G. Finlay and R. George.” Journal of Medical Ethics, Vol. 37, No. 3 (2011), pp. 171–174.

[3] Meier et al., “A national survey of physician-assisted suicide and euthanasia in the US,” New England Journal of Medicine (1998). p 1193-1201.

Emanuel et al., “The practice of euthanasia and physician-assisted suicide in the US: Adherence to proposed safeguards and effects on physicians.” Journal of the American Medical Association (1998). p. 507-513.

Battin et al. “Legal Physician-Assisted Dying in Oregon and the Netherlands: Evidence Concerning the Impact on Patients in “Vulnerable” Groups.” Journal of Medical Ethics, Vol. 33, No. 10 (2007), pp. 591-597.

[4] Kitzhaber, “The values behind state health decisions,” The Oregonian, 8/26/2008

[5] Joondeph, correspondence with Death with Dignity National Center and Compassion & Choices

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