Death with Dignity

What Are We Talking About?

Before we delve into the specifics of where and how this practice is allowed, let’s first understand what the process of Death with Dignity entails:

1. Patient’s Request: The patient, typically suffering from unbearable pain due to a terminal illness, must make a voluntary, informed decision to end their life. This involves making one written and two oral requests, with waiting periods in between. The written request must be witnessed by two individuals who can confirm the patient’s identity, mental competence, and voluntariness of the request.
2. Physician Evaluation: The patient’s attending physician must confirm the patient’s diagnosis and prognosis and verify that the patient is capable of making an informed decision. This includes ensuring the patient understands their medical condition, prognosis, potential risks associated with taking the medication, and feasible alternatives such as hospice care and pain control.
3. Second Opinion: A second physician must independently confirm the patient’s diagnosis, prognosis, and mental competence.
4. Mental Health Referral: If either physician believes the patient’s judgment may be impaired by a psychiatric or psychological disorder (such as depression), the patient must be referred for a psychological evaluation.
5. Prescription: If all requirements are met, the physician writes a prescription for a lethal dose of medication. The type of medication can vary, but it is typically a barbiturate.
6. Administration: The patient must self-administer the medication. This requirement is intended to ensure that the act is voluntary. The medication is typically taken orally but can also be taken through a feeding tube or suppository if the patient cannot swallow.
7. Follow-Up: After taking the medication, the patient typically falls asleep within minutes and dies peacefully within a few hours. The physician or another healthcare professional may be present at the patient’s request, but this is not required.

It’s important to note that the specific process can vary by state and country. The rituals or events that precede or follow a death with dignity procedure can vary greatly depending on the individual’s personal, cultural, and religious beliefs, as well as their physical condition and the preferences of their loved ones. Here are some possibilities:

Before the Procedure:

• Saying Goodbye: The individual may wish to say personal goodbyes to their loved ones. This could be in the form of individual conversations, letters, or a gathering with family and friends.
• Legacy Projects: Some individuals may choose to work on projects that leave a legacy, such as writing memoirs, recording messages for loved ones, creating art, or compiling family histories.
• Planning for the End: The individual may discuss their wishes for the procedure itself, such as where it will take place, who will be present, and what kind of atmosphere they want (for example, they may want certain music playing or specific items nearby).
• Spiritual Rituals: If the individual is religious, they may wish to participate in certain rituals or receive sacraments. For example, a Catholic person might request the Anointing of the Sick.

After the Procedure:

• Memorial Service or Funeral: Loved ones may hold a service to remember and celebrate the individual’s life. The format can vary widely depending on cultural and personal preferences.
• Grief Counseling: Bereavement support or grief counseling may be beneficial for loved ones dealing with their loss.
• Handling of Remains: Depending on the individual’s wishes and cultural practices, the body may be buried, cremated, donated to science, or handled in another way.
• Continuing Bonds: Loved ones may find ways to maintain a sense of connection with the deceased, such as visiting their grave, celebrating their birthday, or keeping mementos.

It’s important to note that, putting aside the moral and ethical arguments for the moment, there’s no “right” way to approach Death with Dignity. Most importantly, the individual’s wishes are respected, and their dignity is maintained.

States Supporting Death with Dignity

The following states have enacted Death with Dignity laws:

• California (End of Life Option Act; approved in 2015, in effect from 2016)
• Colorado (End of Life Options Act; 2016)
• District of Columbia (D.C. Death with Dignity Act; 2016/2017)
• Hawaii (Our Care, Our Choice Act; 2018/2019)
• Maine (Maine Death with Dignity Act; 2019)
• New Jersey (The New Jersey Medical Aid in Dying for the Terminally Ill Act; 2019)
• New Mexico (Elizabeth Whitefield End of Life Options Act; 2021)
• Oregon (Oregon Death with Dignity Act; 1994/1997)
• Vermont (Patient Choice and Control at the End of Life Act; 2013)
• Washington (Washington Death with Dignity Act; 2008)

While Montana does not have a specific statute, a 2009 Supreme Court ruling allows physicians to honor a terminally ill, mentally competent patient’s request for medication to hasten death.

Pros and Cons

This is a very sensitive topic, and concerns range from morality to abuse. Here are some of the more commonly cited benefits and risks of allowing Death with Dignity:

Benefits

• Patient Autonomy: Death with Dignity laws respect the autonomy of terminally ill patients, allowing them to make their own end-of-life decisions. This can provide a sense of control over their own life and death.
• Alleviation of Suffering: The suffering can be unbearable for patients with terminal illnesses. PAS can hasten death and potentially alleviate prolonged physical and psychological suffering.
• Preservation of Dignity: Some patients may wish to avoid the loss of autonomy and dignity that can come with the progression of a terminal illness. PAS allows them to die on their own terms.
• Peace of Mind: Simply having the option of PAS, whether used or not, can comfort patients, knowing they have a choice if their suffering becomes too great.

Risks

• Potential for Abuse: There are concerns that vulnearable populations (like the elderly, disabled, or economically disadvantaged) could be coerced into PAS or choose it due to a lack of access to quality palliative care.
• Medical Ethics: Some healthcare professionals are uncomfortable with PAS, viewing it as contradictory to their healing role. This can lead to conflicts within the medical community.
• Slippery Slope: Some worry that legalizing PAS could lead to a slippery slope, with the loosening of regulations over time and potential expansion to non-terminal patients.
• Psychological Impact on Family and Medical Staff: The decision to pursue PAS can have a significant emotional impact on both family members and healthcare providers involved.
• Religious or Moral Objections: Many people have strong religious or moral beliefs about the sanctity of life, which can lead to personal distress and societal controversy.

It’s important to note that implementing Death with Dignity laws includes safeguards to mitigate potential risks, such as confirmation of terminal diagnosis, mental competency assessments, and waiting periods. However, the effectiveness of these safeguards is also a subject of ongoing debate.

Key Requirements for Death with Dignity by State

• California (End of Life Option Act): Adult suffering from a terminal disease, mentally competent to make healthcare decisions.
• Colorado (Prop 106): 18 years old, mentally capable, in the final stages of a terminal illness (six months or less to live), must request and self-administer the medicine.
• Hawaii (Our Choice, Our Care Act): Mentally capable, terminally ill with six months or less to live.
• Maine (Maine Death with Dignity Act): 18 years or older, suffering from a terminal disease, able to make a request for medication to end their life.
• Montana (Court Ruling): Court ruling allows physicians to assist patients in ending their lives by prescribing lethal medications to be self-administered by the patient.
• New Jersey (Aid in Dying for the Terminally Ill Act): Law passed, awaiting Governor’s signature.
• New Mexico (Court Ruling): The court ruling allows mentally competent adults with a terminal prognosis the right to death with dignity.
• Oregon (Death with Dignity Act): Law does not specify requirements beyond being an adult with a terminal illness.
• Vermont (Patient Choice and Control at the End of Life Act): Law does not specify requirements beyond being an adult with a terminal illness.
• Washington (Washington Death with Dignity Act): Law does not specify requirements beyond being an adult with a terminal illness.
• Washington, D.C. (D.C. Death with Dignity Act): Law does not specify requirements beyond being an adult with a terminal illness.

Specific requirements can vary by state and may include additional stipulations such as residency, multiple requests (oral and written), waiting periods, and confirmation of diagnosis and prognosis by multiple physicians. It is best to refer to the specific legislation or consult a healthcare provider for the most accurate information.

One of the key requirements of Death with Dignity laws is that the individual must be mentally competent, or lucid, at the time of requesting and administering the life-ending medication. This requirement is in place to ensure that the decision is voluntary, informed, and not the result of coercion or impaired judgment.

However, this requirement presents a significant challenge for individuals with advanced dementia, Alzheimer’s, or other neurodegenerative disorders. These conditions often impair cognitive function to the point where the individual may not be able to understand the nature and consequences of their decisions, including the decision to end their own life.

As dementia progresses, individuals may lose the ability to recognize their loved ones, communicate effectively, and make informed decisions about their care. This means that by the time their suffering becomes unbearable, they may no longer be considered mentally competent to request physician-assisted suicide, even if they expressed a desire for it while they were still lucid.

This raises complex ethical and legal questions. On the one hand, there is a desire to respect the autonomy and prior wishes of the individual. On the other hand, there is a need to protect individuals who may not fully understand their actions from making a decision as irreversible as ending their own life.

Some have proposed potential solutions, such as advance directives for physician-assisted suicide, where individuals could specify their desire for assisted death if they develop severe dementia or similar conditions. However, this approach is controversial and not currently allowed under existing Death with Dignity laws in the United States. Critics argue that an individual’s wishes might change over time, and it’s impossible to confirm the wishes of someone who can no longer communicate or make decisions.

This is a very challenging issue with no easy answers, and it’s a topic of ongoing debate in the fields of medical ethics and law. As we grapple with these questions, it’s crucial to remember the core principle at the heart of the Death with Dignity movement: respect for individual autonomy and the desire to alleviate suffering. Regardless of where one stands on the issue, these values resonate with us all.

In closing, Death with Dignity is a deeply personal and complicated issue that touches on our fundamental beliefs about life, death, and personal autonomy. As we continue to debate this issue, it’s crucial to keep the conversation respectful, empathetic, and informed by the real experiences of those directly affected.

Additionally, there is a need to accommodate those with neurological diseases where the current legislated requirements preclude their eligibility for this procedure. Whether or not one supports the right to Death with Dignity, we can all agree on the importance of ensuring that every individual is treated with dignity and respect in their final days.

Further Reading

• Death with Dignity
• States
• Assisted Suicide (podcast)
• Pros and Cons of Physician Aid in Dying