Compassion & Choice is promoting “aid in dying,” a movement that wants to shift personal decisions about the ending of life from government control to individual autonomy.

President Barbara Coombs Lee, who visited Hawaii for a series of talks about aid in dying last week, says Hawaii a statute already provides a legal foundation to help patients who want to receive lethal medication from their doctors.

In this second and final report, Coombs Lee talks about the experiences of four other states with “death with dignity,” as aid in dying is sometimes called. Part 1 details her group’s effort to make it easier for individuals to make end-of-life decisions.

Civil Beat: Let’s talk briefly about where the nation is in terms of aid in dying. I believe it’s just Oregon, Washington and Montana that have laws.

Barbara Coombs Lee: Aid in dying is most affirmatively legal in Oregon and Washington, where a specific, governmental, regulatory framework — a specific formulaic process, quite elaborate reporting requirements to the government — are in place. In Montana, there is no set regulatory scheme, there are no such reporting requirements. The Montana Supreme Court has looked at the legal landscape and said, “We think the law of Montana promotes autonomy and self-determination at the end of life, and we don’t see any law that would prohibit a patient from asking a physician for life-ending medication and a physician giving it.”

The Montana Legislature then considered two bills, one that would have overturned the Supreme Court — that was defeated — and a bill that would have made it more clearly affirmatively legal. Opponents of aid in dying didn’t want that passed, either — to sort of codify some safeguards and guidelines — they didn’t want that. So, we’re left in Montana with the general outline the Supreme Court provided: must be a mentally competent, terminally ill adult; a resident of Montana; must initiate a request to their physician; if the physician provides the medication, the patient must self administer it.

What would the medication be?

For the most part, they are a short-acting barbiturate class of drugs.


And actually, that guidance works quite well, because then the details of what is best practice gets turned over to the medical profession, where best-practice standards evolve for every medical procedure and treatment. So, it means aid in dying in Montana is right there with withdrawing a ventilator, assisting a patient who has decided to discontinue dialysis, stopping feeding tubes, deactivating pacemakers, stopping eating and drinking with palliative support — all of those other intentional end-of-life decisions that may advance the time of death for which the medical community is called to provide support and medical treatment. And there are good practices, there are careful evaluations, there is good palliative care to be offered. But that’s not regulated in statute.

So, that brings us to Hawaii, where Hawaii law is at least as generous toward end-of-life decision-making as Montana law. It’s actually more generous.

Explain that.

Well, there is no (Hawaii) 1909 law, for example, in Montana that says a dying person may request any remedial treatment. And there is no specific pain law in Montana, either, that says patients may request medication to end their suffering even if it advances the time of death. There is already this and other laws on the books in Hawaii that the Montana Supreme Court didn’t have to look at.

Any other states moving in that direction?

Well, lo and behold, we just discovered a few weeks ago that aid in dying has been legal in Georgia since 1994. And it came to light actually in the context of a criminal prosecution of some behavior that was assisting in a suicide. But the statute that the legislators crafted in 1994 actually had two parts. They wanted very much to keep their flamboyant mavericks — Kevorkian-type people — in check, but they also wanted to be protective of personal and private end-of-life decisions.

So, they put two components in the bill. One was to commit an act and the other was to speak of it publicly. The attorney general actually argued before the Georgia Supreme Court that if a private conversation between a patient and his physician ended up in a life-ending medication prescription, that that was perfectly legal in Georgia. And so, we’ve had a completely kind of unregulated practice in Georgia since 1994, and it hasn’t risen to public consciousness.

Here in Hawaii, I have covered many hearings on Death With Dignity bills — that’s what we call it here, “death with dignity” — but it’s essentially doctor-assisted suicide.

Except that we don’t use “suicide.”

Agreed, “aid in dying.” But that’s a red flag word of some sort — suicide — isn’t it?

It really is a red-flag word because patients who are dying and family members who are standing by dying patients are affronted by it. … It implies a disordered thinking. It implies a psychological impairment. It implies a mental-health illness. And, it’s also inaccurate, because Oregon, the pioneer state for aid in dying, also happens to be the strictest state in the country in legislating and enforcing laws against assisting suicide. Oregon is the only state where it’s not only illegal to assist a suicide, it is also illegal to traffic in the paraphernalia of a suicide — bags and helium tanks and things like that.

The two biggest arguments I have heard against having death with dignity in Hawaii, or aid in dying, one is that folks involved with hospices and palliative care, they say that that is really the way to go — they have medication and it allows you to have your family around you, it’s managed, but you stop short of having a doctor help you end your life.

And the second argument I hear is about the sanctity of life, often based on religions grounds. Also, some concern that this may lead to — not eugenics — but that some how we would weed out the people in society that are weak and infirm, and that they might be subject to this kind of law.

First, I think offering people the self-determination, the comfort of aid in dying, is perfectly compatible with hospice and palliative care. Hospice and palliative care have thrived in Oregon since 1997, when the Oregon Death with Dignity Act came on line. Almost all — in some years, 98 percent — of the patients who do ingest self-administered life-ending medication in Oregon, are enrolled in a hospice.

So hospice and aid in dying are compatible?

They are absolutely compatible. But the fact is that as good as hospice care is — and it is excellent — it can never alleviate all kinds of suffering if the patient is unwilling to be sedated to unconsciousness or unwilling to submit to this natural progression that often results in delirium and unconsciousness. If a patient has some sort of symptoms that are beyond treating well with the usual hospice treatment — things like breathlessness come to mind, complete fatigue, so much so that you just cannot move; unrelieved nausea and vomiting — there are some symptoms that are just beyond the reach of even very good hospice care. And those people who have those symptoms shouldn’t have to linger with them or endure them.

And then the impact on vulnerable populations …

You put it much better than I did.

I think that it was a legitimate concern. It was a question. And that’s why we have “laboratories of the states.” And that’s why it was good that Oregon has been so fastidious in its reporting all these years. Because now we have almost 15 good, solid years of meticulous reporting. And it was absolutely clear that vulnerable populations are not impacted at all.

The choice, the decision, the power resides with patients themselves. There really is no room for coercion with all of the safeguards and good medical practice accompanying them. The statistics are quite the opposite — by and large people who make a request and have the wherewithal to follow through and obtain the medication, they are mostly highly educated. People who are used to exercising self-determination in their lives. …

But the wonderful thing in having aid in dying is that it does level the playing field. So, people who are not privileged to have special relationships with their physicians, to have a conversation … they’re protected by the law. They can have that conversation.

What will it take to get aid in dying adopted — to become the norm across the country?

I don’t think it will ever become the norm. Our goal is that it become accepted as a legitimate choice among all of the other choices. There is no one good way to find a peaceful death, (but) there is the best way for you given your circumstances, your diagnosis, your prognosis, the medications you’re on, what your family thinks, who you are, your history, your values and beliefs. There is probably a best way for you, but there is not a best way for everyone.

Our hope is that aid in dying not become the norm but be added to that mix for those people — those few people, really; less than one in a thousand — for those few people for whom it is the best choice. And for those people who never actually make that choice, to receive the piece of mind to know that they could if they wanted to.

So, what will it take? We do not believe that it will require more government-regulated laws like Oregon’s and Washington’s. … The data has proven that the process is safe. It is time to move out of the laboratory of the state, to take the data we have achieved there and to move it into medical practice.

We’re in that phase now. Montana was the first state in which that happened, with the help of a Supreme Court ruling. Hawaii is a state where that is happening without the benefit of a Supreme Court ruling but with a whole constellation (of laws) . … We see a pattern of respect for autonomy that is manifest in many places in Hawaii statute.

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