Washington became the second state in the U.S. (after Oregon) to legalize assisted suicide for terminally ill patients. Washington voters narrowly approved the Washington Initiative 1000, also known as the Death with Dignity initiative, with 57.9 percent of the vote.
Initiative 1000 allows mentally competent but terminally ill adults—with less than six months to live—the right to request and then self-administer a lethal overdose of medicine. The measure requires two oral and one written request from the patient. They must be voluntary requests, without coercion, and verified by two physicians. There is a 15-day waiting period between the first oral request and the written request.
Two doctors must diagnose the patient, determine that he or she is competent, and then make independent assessments about the patient's length of life before consent for a lethal prescription is allowed. Patients must be informed of all other options, including palliative and hospice care. There is a 48-hour waiting period between the written request—which must be signed by two independent witnesses, at least one of whom is unrelated to the patient or employed by the health care facility—and the writing of the prescription.
The law, which will go into effect in July 2009, explicitly prohibits lethal injections and euthanasia. Patients who want to take advantage of the law, therefore, must self-administer the oral drugs. Physicians cannot be forced to participate in assisted suicide and can declare their facilities “assisted suicide-free zones”—places where doctors will not participate and a person cannot self-administer lethal drugs.
Patients with amyotrophic lateral sclerosis (ALS), aggressive brain tumors, painful cancers, and other terminal neurodegenerative diseases such as late stage multiple system atrophy would be the neurology patients most likely to take advantage of this law, says Michael Weiss, M.D., associate professor of neurology at the University of Washington.
“Ironically, many such patients won't qualify legally, because the terminal stages of these diseases tend to deprive them of their ability to self-administer medication—which constitutes the key distinction between physician-assisted death and euthanasia,” says James Gordon, M.D., clinical associate professor of neurology at the University of Washington.
“As the patient needs to be competent to make this decision, the measure will not apply to late stage dementias such as Alzheimer's disease,” says Dr. Weiss. “Patients will likely be driven by a number of motivating factors, including intractable pain and loss of independence or ability to communicate.”
Dr. Weiss says he doesn't anticipate that large numbers of terminally ill patients will want to take advantage of the law. “Since the enactment of the Oregon Death with Dignity law in 1998, only approximately 300 patients have chosen to take advantage of the law in ending their lives,” he says, adding that Washington's initiative was modeled closely on Oregon's law.
Mark Yerby, M.D., associate clinical professor of neurology, OB-Gyn, and public health and preventive medicine at Oregon Health and Sciences University, says that in regards to the Oregon law, “many patients obtain the medication needed but fail to actually use it, expressing comfort in knowing they can if their quality of life becomes unbearable. The freedom to call one's own shots at such a time is invaluable.”
Dr. Weiss speculates that many neurologists will be unwilling to assist because the law doesn't take into account several complex issues. For example, physicians must determine when the patient is likely to succumb to their disease. In the case of patients with ALS, whose average life expectancy is two to five years, this can be challenging because a significant number of patients live beyond 10 years.
“The definition of ‘terminal’ as ‘six months to live, regardless of treatment’ is a legal fiction, even if it is useful for some purposes,” says Dr. Gordon. “If anything, physicians tend to err to the side of caution when it comes to prognosis: witness how long we tend to wait before referring to hospice—far too long in many, many cases.”
Another disadvantage is that the law does not stipulate a mandatory psychiatric evaluation for depression or cognitive impairment, which is not uncommon in many patients and obviously influences their decision-making. Also, there are no obvious safeguards against coercive family members or caretakers who want the patient to take advantage of the law.
Initiative 1000 points to the need for greater focus on initiating palliative and hospice care early to alleviate suffering, as well as expanded coverage of such care by insurance companies, Dr. Weiss says. “The Washington Death with Dignity Act serves only to diminish the immeasurably valuable role of the palliative specialist in caring for the terminally ill.” (Palliative care reduces the severity of the symptoms of a disease rather than ending progression of the disease itself or curing it completely.)
Dr. Yerby noted that the recognition and quality of terminal care has greatly improved in Oregon, in terms of greater access to hospice care, more attentive care by physicians, and better management of chronic pain. “I would hope this would also occur in Washington,” he says.
Euthanasia vs. Assisted Suicide
If someone other than the patient performs the last act that intentionally causes a patient's death—such as giving a lethal injection—euthanasia has occurred. In assisted suicide, the patient who dies performs the last act that causes death, such as swallowing the overdose of drugs that was provided by a doctor for causing death.