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Washington state voters approve physician-assisted suicide
On Nov. 4, 2008, Washington state voters passed a ballot initiative giving terminally ill patients with six months to live the right to have a physician prescribe lethal drugs for the patient to self-administer to bring about his or her death.
With the passage of the initiative, referred to as "I-1000," Washington became the second state, after Oregon, to approve physician-assisted suicide.
According to those Medical Ethics Advisor spoke with in that state, the issue was divisive and heatedly debated, with big dollars spent on both sides of the issue.
Still, the ballot initiative, the Washington Death with Dignity Act, passed by a wide margin, according to early reports from The Seattle Times. The act is scheduled to take effect in March 2009.
"The whole purpose is to relieve suffering of people who are dying, and I think everybody's in favor of that," says Tom Preston, MD, board member and medical advisor of the group Compassion & Choices of Washington, which brought the initiative to the ballot. "Some say you can do it adequately with palliative care . . . and I'm a great supporter of hospice. Nevertheless, there is 5% to 10% of the people who do suffer greatly, even in hospice."
Preston acknowledges that "there's some people whose ideology or religion is such that they feel this is absolutely wrong — and they may say that it hurts them to [have patients] do this, but you could say that about a lot of things," he says.
"So, yes, I think that furthermore, we all know . . . that most physicians do help their patients die in one way or another, but they do it to avoid the appearance of doing something . . . So there's a lot of hypocrisy, saying, 'Well, we can't do it openly,'" Preston says.
Preston believes that "autonomy should be most important, unless someone's autonomous action hurts someone else."
The Washington Death with Dignity Act requires, among many other things, that a patient be at least 18 years old and a resident of Washington.
The patient must initiate a written request for medication, which must be witnessed by "at least two individuals who, in the presence of the patient, attest that to the best of their knowledge and belief the patient is competent, acting voluntarily, and is not being coerced to sign the request."
One of those witnesses is not permitted to be a relative of the patient "by blood, marriage, or adoption."
The attending physician, who must make the initial determination of whether a patient "has a terminal disease, is competent, and has made the request voluntarily," also must convey to the patient "the probable result" of taking such lethal medication, as well as advise him or her of alternatives to physician-assisted suicide, including palliative care and hospice care.
A consulting physician must be called in for medical confirmation of the diagnosis, and he or she also must determine that the patient is competent and acting voluntarily.
Patients are allowed under the act to rescind their decision at any time and "in any manner."
There is a 15-day waiting period between the time of the request and the time the lethal drugs are prescribed.
Medical association opposed I-1000
The Washington State Medical Association (WSMA), with offices in Seattle and Olympia, opposed I-1000, based on the testimony of most of its membership, who spoke at a meeting of that organization's reference committee, prior to it going to the WSMA's policy-making House of Delegates (HOD) meeting in 2007.
At the 2008 HOD meeting in September, that body passed a resolution that required the association to publicize its position against I-1000.
In 2007, however, the reference committee was considering a resolution to move to a neutral position on physician-assisted suicide from its earlier 1993 position totally against physician-assisted suicide.
"And that testimony really came from oncologists, hospice medical directors, and palliative care specialists, and it was pretty powerful," WSMA president, Cindy Markus, MD, JD, tells MEA.
"We were impressed by the testimony from the oncologists and hospice physicians that if people are contemplating suicide, then they're not getting the kind of care that they should get," she says. "And one of our efforts, ever since the 1993 initiative, has been to try to improve physicians' ability to treat the pain and other discomforts of terminal life care and create a situation where people don't need the option — or don't feel they need the option — to end their lives."
Among WSMA's concerns regarding I-1000 is that there is no requirement that there be a psychiatric evaluation for patients to determine whether they may be clinically depressed, Markus says.
"We worry that even if you give them the prescription at one moment in time, that they can, of course, become depressed subsequently and perhaps prematurely end their lives," she says.
The WSMA also is "pretty concerned," Markus says, that there is no requirement that the patient's family be notified of his or her plans, although there is a requirement that the patient be "counseled" to discuss it with his or her family.
"We as physicians know that often the anger that these patients' families may feel after such an event as this can be directed at physicians, and of course, we don't want our patients' families to be angry with us," she says.
The requirement that any measures that a physician takes to help a patient with his or her suicide under this act must be reported to the state Department of Health is another concern of the WSMA. As the initiative is scheduled to take effect in March, WSMA says this does not give the state authority sufficient time to establish a framework and tracking mechanism for this requirement.
"As I recall, there's no penalty for not reporting, so things could happen under the radar and under the table that we will never know about," Markus says.
A physician's view
J. Randall Curtis, MD, MPH, professor of medicine and adjunct professor of health services at the University of Washington, describes I-1000 and physician-assisted suicide as "a complicated issue." Curtis has done studies in end-of-life care.
"I think the medical ethics, as well as the palliative care fields, are deeply divided on this issue, and I think that very well meaning and principled individuals on both sides of the debate feel very strongly about their points of view," he says.
Aside from being difficult to resolve from a "purely normative ethical standpoint," Curtis says he thinks that until high-quality palliative care is available for all patients facing a terminal illness, physician-assisted suicide will be among the options considered.
"And I think that the majority of patients at the end of life can have symptoms managed by high-quality palliative care, making this option unnecessary," he says.
But, at the same time, it's difficult to be "absolutely dogmatic about it," Curtis says, noting that some people just like knowing they have physician-assisted suicide as an option, even if they never decide to utilize it.
"There's another reality of this dilemma — this problem," he says. "In my experience, high-quality palliative care [includes] the option of what people call palliative sedation, meaning that if symptoms become completely uncontrollable at the end of life," it is possible to have people sedated to the point that they are unaware of what is happening.
Curtis says that if you include the option of palliative sedation within high-quality palliative care, it avoids some of the risks associated with physician-assisted suicide. Those risks include "incorrect diagnoses, which happen from time to time, coercion, or having people feel like they really must exercise this option to protect others from distress or financial ruin or what have you."
Will physicians participate?
According to an essay in the Dec. 11 issue of The New England Journal of Medicine,1 in Oregon in 2007, 45 physicians in that state wrote the 85 prescriptions issued under that state's physician-assisted suicide, or Death with Dignity Act.
"Because of the nature of their medical practices or personal objections to involvement, most physicians in Oregon have never written a prescription for a lethal dose of medication . . .," wrote the essay's author, Robert Steinbrook, MD.
Curtis agrees that, while he has not seen surveys on the issue, many physicians will not participate.
"I think there are a number of physicians who feel like this really is not a role physicians ought to be playing," he tells MEA.
Since I-1000 was an initiative put before the public by a citizens' group — which had a former state governor, Booth Gardner, as its spokesman, this issue received widespread attention.
Markus notes that to try to prevent the initiative from taking effect would require a two-thirds majority from the House and Senate. She notes that I-1000 was a "very, very, very contentious ballot initiative within the state."
So, at this point, Markus says, the WSMA "has decided not to try to modify the initiative through the legislative process.
"I just don't think there's much stomach in Olympia, in our capital, to try to change something that the voters so resoundingly passed," she says.
"We have made our point known, and the voters spoke, and I think we're going to leave it that way, unless, of course, we hear from members or citizens that there are problems, and then obviously, we would reconsider that position," Markus adds.
(Editor's note: Just prior to Medical Ethics Advisor going to press, the Associated Press reported that a Montana state district judge issued a ruling that Montana residents have the right to physician-assisted suicide. MEA will report on this in future issues.)
For more information about Washington state's new physician-assisted suicide law, contact: