The Danger of
AssistedSuicide Laws
Part of the Bioethics and
Disability Series
National Council on Disability
October 9, 2019
National Council on Disability (NCD)
1331F Street NW, Suite 850
Washington, DC 20004
The Danger of Assisted Suicide Laws: Part of the Bioethics and Disability Series
National Council on Disability, October 9, 2019
This report is also available in alternative formats. Please visit the National Council on Disability (NCD)
website (www.ncd.gov) or contact NCD to request an alternative format using the following information:
[email protected] Email
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The views contained in this report do not necessarily represent those of the Administration, as this and
all NCD documents are not subject to the A-19 Executive Branch review process.
National Council on Disability
An independent federal agency making recommendations to the President and Congress
to enhance the quality of life for all Americans with disabilities and their families.
Letter of Transmittal
October 9, 2019
The President
The White House
Washington, DC 20500
Dear Mr. President:
On behalf of the National Council on Disability (NCD), I am pleased to submit Assisted Suicide Laws
and Their Danger to People with Disabilities, part of a five- report series on the intersection of disability
and bioethics. This report, and the others in the series, focuses on how the historical and continued
devaluation of the lives of people with disabilities by the medical community, legislators, researchers,
and even health economists, perpetuates unequal access to medical care, including life- saving care.
NCD has long opposed assisted suicide laws. In 1997, after a thorough review of the forms of
discrimination people with disabilities experienced in American society, NCD issued Assisted Suicide:
ADisability Perspective, opposing legalization of assisted suicide, concluding that the evidence
indicated that the interests of the few people who would benefit from assisted suicide were “heavily
outweighed by the probability that any law, procedures, and standards that can be imposed to regulate
physician- assisted suicide will be misapplied to unnecessarily end the lives of people with disabilities.”
Instead, NCD called for a comprehensive, fully- funded, system of assistive living services for people
with disabilities.
Eight years later, in 2005, reaffirmed its position opposing the legalization of assisted suicide. The
nation had observed the implementation of the Oregon assisted suicide law, and the evolution of
cultural attitudes toward so- called “mercy killing,” of both the medical and non- medical variety. Jack
Kevorkian was convicted of second- degree murder for committing active euthanasia of a man with
ALS, utilitarian euthanasia advocate Professor Peter Singer was hired for a prestigious bioethics chair
at Princeton University, two movies favorably depicting euthanasia of people with quadriplegia won
Oscars, and numerous courts upheld the right of a guardian to starve and dehydrate a severely brain
injured but healthy woman in Florida. The dangers to people with disabilities based on the devaluation
of their lives was ever clearer.
Assisted Suicide Laws and their Danger to People with Disabilities reexamines the issue of assisted
suicide in light of NCD’s prior reports, brings NCD’s earlier analysis up- to- date, and finds that the
dangers and harms that NCD identified in 1997 and 2005 are at least as significant today. The report
describes, among other things, a double standard in suicide prevention efforts where people with
disabilities are not referred for mental health treatment when seeking assisted suicide, while people
without disabilities receive such referrals. The report recommends steps that must be taken at the
federal and state levels to ensure that people with disabilities have a system of assisted services and
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Suite 850
Washington, DC 20004
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supports; that medical providers inform patients seeking assisted suicide of these supports; and that
medical providers receive training in disability competency and disability- risk factors for suicide.
NCD stands ready to assist the Administration, Congress and federal agencies to ensure that people
with disabilities are not steered toward ending their lives due to a lack of supports and medical
providers who are not required to help patients find alternatives.
Respectfully,
Neil Romano
Chairman
(The same letter of transmittal was sent to the President Pro Tempore of the U.S.Senate and the Speaker of the
U.S. House of Representatives.)
2 National Council on Disability
National Council on Disability Members and Staff
Members
Neil Romano, Chairman
Benro Ogunyipe, Vice Chairperson
Billy Altom
Rabia Belt
James Brett
Daniel Gade
Andrés Gallegos
Wendy S. Harbour
Clyde Terry
Staff
Phoebe Ball, Legislative Affairs Specialist
Stacey S. Brown, Staff Assistant
Joan M. Durocher, General Counsel & Director of Policy
Lisa Grubb, Executive Director
Netterie Lewis, Administrative Support Specialist
Amy Nicholas, Attorney Advisor
Nicholas Sabula, Public Affairs Specialist
Amged Soliman, Attorney Advisor
Anne Sommers, Director of Legislative Affairs & Outreach
Ana Torres-Davis, Attorney Advisor
Keith Woods, Financial Management Analyst
The Danger of Assisted Suicide Laws 3
4 National Council on Disability4 National Council on Disability
Contents
Acknowledgments ........................................................9
Executive Summary
.....................................................11
Purpose
......................................................11
Background
...................................................11
Key Findings
..................................................11
Safeguards and Their Limitations
..............................11
Lack of Data Collection, Oversight, andInvestigation
of Mistakes andAbuse
.....................................12
How Are Assisted Suicide Laws Viewed
by Disability Organizations?
.................................12
Recent Issues and Events: Bringing theNCD
Position Up to Date
........................................12
Key Recommendations
..........................................13
Congress
..................................................13
The US Department of Health and Human Services (HHS)
.........13
The Substance Abuse and Mental Health Services
Administration (SAMHSA)
...............................13
The National Institute on Disability, Independent Living,
and Rehabilitation Research (NIDILRR)
....................13
HHS Ofce for Civil Rights (OCR)
...........................13
State Legislatures, and State Referenda and Initiatives
............14
Primary Care Practitioners, Specialty Providers, Clinics,
Hospitals, Laboratories, Diagnostic and Therapy Centers,
and Other Healthcare Services
...............................14
Medical Schools and Other Healthcare Professional Education
and Training Programs
.....................................14
The Danger of Assisted Suicide Laws 5
Methodology ..................................................14
Introduction and Background
....................................14
Acronym Glossary
.......................................................17
Chapter1: Safeguards and Their Limitations
.................................19
What Are the Safeguards inAssistedSuicide Laws?
.................19
Are There Problems with TheseSafeguards?
.......................19
Assisted Suicide Instead ofMedicalTreatment
...................20
Mistakes in Diagnosis and Prognosis
...........................21
Depression and Demoralization
...............................23
Demoralization and Internalized Oppression
of People with Disabilities
..................................26
Doctor Shopping
...........................................27
Family and Economic Pressures
...............................28
Good Faith
................................................29
Physicians Hold Disproportionate Power
........................29
Safeguards Are Gradually Diminishing
.........................31
Chapter2: Lack of Data Collection, Oversight, andInvestigation
of Mistakes and Abuse
...................................................33
Minimal Data and Scant Oversight
................................33
Conclusions Regarding the Data ThatIs Available
...................37
Trends in Data Collection Show Decrease over Time
.................37
Chapter3: How Are Assisted Suicide Laws Viewed byDisability Organizations?
......39
Chapter4: Recent Issues and Events: Bringing theNCD Position Up to Date
.......41
Sense of Congress Resolution
....................................42
The Risks of Abuse
.............................................42
Loosening oftheRules
..........................................43
Double Standard in Suicide Prevention
............................46
Evidence of Suicide Contagion
...................................46
Suicide Prevention and Disability
.................................47
6 National Council on Disability6 National Council on Disability
Consequences for People with Intellectual and Developmental
Disabilities
..................................................47
People of Color, Healthcare Disparity, and Assisted Suicide Laws
.......47
Improvements in Palliative Care
..................................49
The Criminalization of Pain
......................................49
Chapter5: Recommendations
.............................................51
Endnotes
...............................................................57
The Danger of Assisted Suicide Laws 7
8 National Council on Disability8 National Council on Disability
Acknowledgments
This report is part of a series of reports on bioethics and people with disabilities which was developed
through a cooperative agreement with the Disability Rights Education & Defense Fund (DREDF). The
National Council on Disability (NCD) appreciates the work of Marilyn Golden, Senior Policy Analyst,
DREDF, who contributed her expertise in the development of this report, and who shepherded the
entire report series in cooperation with NCD. We also thank those who participated on the Advisory
Panel, in interviews, and in the stakeholder convening, whose knowledge and willingness to share
information helped make this series possible.
The Danger of Assisted Suicide Laws 9
10 National Council on Disability
Executive Summary
Purpose
A
s one part of a report series on bioethics,
this report presents information on how
assisted suicide laws may impact policies
and practices related to the delivery of medical
interventions and life- saving medical care for
people with disabilities.
The purpose of this report is to provide an
update to the previous NCD analysis of such
laws, to examine whether the NCD predictions
about the effect of these laws were correct, and
to learn more about the relationship between
assisted suicide laws and the provision of life-
sustaining medical care and palliative care to
people with disabilities. Do misunderstandings
about the quality of life and the value of the lives
of people with disabilities affect the development
and operation of such laws? Are there ways
to reduce or eliminate harms, and improve the
understanding of policy makers, the medical
community, and society in general?
Background
Promoted as a way to relieve suffering at the
end of life, assisted suicide laws, as they have
developed in the United States, generally allow
physicians to prescribe lethal drugs to patients
diagnosed with terminal illness and with a
prognosis of 6 months or less to live, if certain
procedural steps are followed. Many national
disability organizations have taken positions
opposing these laws, due to concerns regarding
their impact on people with disabilities.
Key Findings
Safeguards and Their Limitations
Assisted suicide laws contain provisions
intended to safeguard patients from problems or
abuse. However, research for this report showed
that these provisions are ineffective, and often
fail to protect patients in a variety of ways,
including:
Insurers have denied expensive, life-
sustaining medical treatment but offered to
subsidize lethal drugs, potentially leading
patients toward hastening their own deaths.
Misdiagnoses of terminal disease can also
cause frightened patients to hasten their
deaths.
People with the disability of depression are
subject to harm where assisted suicide is
legal.
Demoralization in people with disabilities
is often based on internalized oppression,
such as being conditioned to regard help as
undignified and burdensome, or to regard
disability as an inherent impediment to
The Danger of Assisted Suicide Laws 11
quality of life. Demoralization can also result
from the lack of options that people depend
on. These problems can lead patients
toward hastening their deaths— and doctors
who conflate disability with terminal illness
or poor quality of life are ready to help them.
Moreover, most health professionals lack
training and experience in working with
people with disabilities, so they don’t know
how to recognize and intervene in this type
of demoralization.
Financial and emotional pressures can
distort patient choice.
Assisted suicide laws apply the lowest
culpability standard possible to doctors,
medical staff, and all other involved parties,
that of a good- faith belief that the law is
being followed, which creates the potential
for abuse.
Lack of Data Collection, Oversight,
andInvestigation of Mistakes
andAbuse
There is a substantial lack of data about
assisted suicide, due not to lack of research,
but to unnecessarily strict privacy and
confidentiality provisions in assisted suicide
laws.
Where assisted suicide is legal, states have
no means of investigating mistakes and
abuse, nor even a complaint mechanism
or similar way for the public to report
suspected problems.
Nevertheless, a few important conclusions
can be gleaned from the minimal available
data, including that assisted suicide laws
require no evidence of consent when the
lethal drugs are administered.
Trends show that the minimal amount of
data collection that was mandated by earlier
state laws is decreasing over time as some
newer states adopt less restrictive assisted
suicide laws.
How Are Assisted Suicide Laws Viewed
by Disability Organizations?
As with many issues and social movements,
individuals are not always in complete unison.
Many national disability rights organizations
oppose the legalization of assisted suicide. All
national groups that have taken a position are
opposed. NCD respects the rights of individuals
to their opinions and acknowledges that some
people with disabilities support, or are not
opposed to, assisted suicide laws, but NCD, for
the reasons described in this report, maintains its
position opposing them.
Recent Issues and Events: Bringing
theNCD Position Up to Date
A Sense of Congress resolution,
H.Con.Res.80, was introduced in the
115th Congress to express that assisted
suicide puts those most vulnerable at risk
of deadly harm. It garnered both Democrat
and Republican cosponsors.
The risks of abuse are significant under
assisted suicide laws and safeguards are not
effective.
Loosening of the rules is increasing in
various aspects of assisted suicide laws— in
eligibility, in who can prescribe lethal drugs,
in whether waiting periods are mandatory,
and in how people with depression
are treated— and in turn, each of these
increases the risk of danger.
12 National Council on Disability
Evidence of suicide contagion in states
where assisted suicide is legal has been
found in several studies.
Improvement in palliative care in the last
decade has the potential to reduce requests
for assisted suicide, though palliative
care should be more socially oriented and
disability informed.
The criminalization of pain: Due to the opioid
crisis, people who depend on opioids to
manage pain often find themselves treated
like criminals. It may become easier to
obtain a prescription to die than one to
relieve pain.
Key Recommendations
Congress
Congress should pass a resolution similar
to H.Con.Res.80, introduced in the
115th Congress, to express the Sense
of the Congress that assisted suicide
puts everyone, particularly people with
disabilities, at risk of deadly harm.
Congress should amend the Social Security
Act to remove Medicaid’s statutory bias for
institutional long- term care rather than long-
term services and supports (LTSS) provided
for people living in the community.
Congress should explore legislative options
to provide home and community- based
LTSS through the Medicare program.
Congress should consider creating a new,
public, long- term care insurance program
topay for a broad range of long- term
supports and services, such as personal
care aides, home modifications, or assisted
living costs.
Congress should consider legislation for
a comprehensive LTSS benefit that is not
means tested.
The US Department of Health and
Human Services (HHS)
The Substance Abuse and Mental
Health Services Administration
(SAMHSA)
SAMHSA should address the mental health
challenges of living with a disability and chronic
conditions, including challenges to people with a
terminal prognosis, in suicide prevention efforts
and education.
The National Institute on Disability,
Independent Living, and Rehabilitation
Research (NIDILRR)
NIDILRR should conduct research on disability-
related risk factors in suicide prevention, as
well as research on people with disabilities who
request assisted suicide and euthanasia.
HHS Ofce for Civil Rights (OCR)
OCR should issue a regulation specifically
requiring nondiscrimination in suicide prevention
services, which states that physicians must
treat a request for assisted suicide or any other
form of hastened death the same, regardless
of whether or not the patient has a disability; an
individual’s expression of wanting to die should
not be explored any less rigorously or fully solely
because the individual has a disability or a chronic
or terminal condition.
As part of this nondiscrimination requirement,
OCR should make clear that all HHS suicide
prevention grants and services must comply
with existing disability rights laws, including the
ADA, Sections504 and 508 of the Rehabilitation
The Danger of Assisted Suicide Laws 13
Act, and Section1557, including the provisions
requiring accessible communications, so that all
videos, documents, and other products ensure
access to persons with disabilities.
OCR should issue a clarifying regulation
pursuant to Section504 and Section1557
and any other relevant federal laws to require
physicians to provide people with disabilities with
information on the full array of available clinical
treatments and available LTSS and to require
that referrals to such treatments and services be
given if requested. The regulation should require
hospitals to create a disability ombudsperson
position who is authorized to facilitate
communication between healthcare providers
and patients with disabilities or their proxies and
advocate on the patient’s behalf, when required,
to ensure that all clinical and LTSS options and
choices are made available.
State Legislatures, and State Referenda
and Initiatives
States should not legalize any form of
assisted suicide or active euthanasia.
Primary Care Practitioners, Specialty
Providers, Clinics, Hospitals,
Laboratories, Diagnostic and Therapy
Centers, and Other Healthcare Services
Primary care practitioners, specialty
providers, clinics, hospitals, laboratories,
diagnostic and therapy centers, and other
healthcare services must offer a full range of
physical, communication, and programmatic
access accommodations for patients with
disabilities that are in compliance with
the Americans with Disabilities Act (ADA)
and Section504 of the Rehabilitation Act,
and that are consistent with culturally
competentcare.
Medical Schools and Other Healthcare
Professional Education and Training
Programs
Medical school and other healthcare
professional education and training
programs, including hospice, should require
courses on skills and competencies needed
to provide quality interprofessional health
care to patients with disabilities.
Methodology
The methodology for this study included a
stakeholder convening held at the beginning of
the project, a literature review of disability studies,
medical and social science articles, and media
articles in popular newspapers and magazines.
The literature review was supplemented by
interviews with stakeholders. Further interviews
and technical assistance were provided by
scholars with expertise on this subject who
served on the project’s Advisory Panel, and by
two disability organizations that have focused on
assisted suicide laws for at least two decades.
Introduction and Background
The National Council on Disability (NCD, also
“the Council”) was an early opponent of the
legalization of assisted suicide, having released
a forceful, thorough statement in 1997
1
that the
Council later reaffirmed in 2005.
2
The dangers
and harms to people with disabilities that NCD
identified appear to be as significant today as
they were in 1997 and 2005.
NCD’s concerns, then and now, stem from the
understanding that if assisted suicide is legal,
some people’s lives, particularly those of people
with disabilities, will be ended without their fully
informed and free consent, through mistakes,
abuse, insufficient knowledge, and the unjust lack
14 National Council on Disability
of better options. No safeguards have ever been
enacted or proposed that can prevent this
outcome.
In 1997, the US Supreme Court left the
question of whether to legalize assisted
suicide, and “the... challenging task of
crafting appropriate
procedures...,” to the
“‘laboratory’ of the
States.”
3
As of this
writing, Oregon (1994),
Washington State (2008),
Vermont (2013), California
(2015), Colorado (2016), Washington DC (2016),
Hawaii (2018)
4
, New Jersey (2019), and Maine
(2019) have legalized assisted suicide. AMontana
Supreme Court decision (2009) may provide a
States Where Assisted Suicide
IsLegal
Oregon (1994)
Washington (2008)
Vermont (2013)
California (2015)
Colorado (2016)
District of Columbia (2016)
Hawaii (2018)
New Jersey (2019)
Maine (2019)
Montana (2009 MT Supreme Court
decision may provide a defense against
criminal charges for doctors who
participate in an assisted suicide)
The Oregon “Death with Dignity
Act” is the statutory model for all
assisted suicide laws and proposed
bills in the United States.
defense against criminal charges for physicians
who practice assisted suicide.
5
Oregon was the first state to legalize assisted
suicide. The Oregon “Death with Dignity Act” is
the statutory model for all assisted suicide laws
and proposed bills in the United States. Forthis
reason, the Oregon
model is a key focus
throughout this report.
Most proponents and
supporters of assisted
suicide, like most of the
medical establishment,
still hold a deficit- oriented medical framework
of disability instead of sociopolitical models of
disability where disability can be neutral, an
identity, the basis for a community, or ever-
evolving depending on barriers and supports in
the environment. Moreover, proponents have
been slow to recognize how crucial LTSS can
be, with home and community- based services
(HCBS) providing many people with options that
make longer lives far more appealing, even when
they have been diagnosed (or misdiagnosed)
as having a terminal illness. And most assisted
suicide laws reference “dignity.” The idea that
hastened death is a pathway to dignity for people
facing physical decline reveals the public’s
extreme disparagement of functional limitations
and a perception that “dignity” is not possible
for people who rely on supports, technology, or
caregivers to be independent or alive.
6
Many hold
the attitude that a person with a disability may be
better off dead than alive. For example, in 2012, an
op-ed author in the Boston Phoenix reported that,
on the night that her boyfriend with a significant
disability suddenly became ill and later died in
the emergency room, a nurse murmured to her,
“Maybe it’s better this way.” She continued,
The Danger of Assisted Suicide Laws 15
I’ll never forget that moment. We’d been
watching a movie together a few hours
before. We had plans to go clubbing. Maybe
it’s better this way?
7
These types of misperceptions and
misunderstandings are rooted in disability
prejudice, and in the context of assisted suicide
laws and policies, they create a deadly mix
that poses multifaceted risks and dangers to
people with disabilities as well as people in other
vulnerable constituencies. These include people
who are aging, are underinsured, have chronic
or progressive conditions, and/or lack privilege in
other ways.
8
16 National Council on Disability
Acronym Glossary
ADA Americans with Disabilities Act
ALS amyotrophic lateral sclerosis
DREDF Disability Rights Education & Defense Fund
HCBS home and community- based services
HHS Health and Human Services
I/DD intellectual and developmental disabilities
LTSS long- term services and supports
NCD National Council on Disability
NIDILRR National Institute on Disability, Independent Living, and Rehabilitation Research
OCR Office for Civil Rights
OPHD Oregon Public Health Division
PCC Physicians for Compassionate Care
SAMHSA Substance Abuse and Mental Health Services Administration
The Danger of Assisted Suicide Laws 17
Chapter1: Safeguards and Their Limitations
“Legalizing assisted suicide means that some
people who say they want to die will receive
suicide intervention, while others will receive
suicide assistance. The difference between these
two groups of people will be their health or dis-
ability status, leading to a two-tiered system that
results in death to the socially devalued group.”
—Diane Coleman
18 National Council on Disability18 National Council on Disability
Chapter1: Safeguards and Their Limitations
“Legalizing assisted suicide means that some
people who say they want to die will receive
suicide intervention, while others will receive
suicide assistance. The difference between these
two groups of people will be their health or dis-
ability status, leading to a two-tiered system that
results in death to the socially devalued group.”
—Diane Coleman
T
his chapter addresses what safeguards
assisted suicide laws provide. Are these
safeguards effective, and if not, what are
their limitations?
What Are the Safeguards
inAssistedSuicide Laws?
US assisted suicide laws and bills contain
a number of provisions pointed to by their
supporters as tight safeguards. For example,
Laurie Wilcox of New Jersey, a nurse “disabled
by [a] life- shortening disease,” wrote in an op-
ed reprinted on the website of Compassion
& Choices, a leading organization promoting
assisted suicide in the United States,
In fact, the New Jersey legislation has
more than a dozen safeguards to prevent
abuse and coercion. For example, two
doctors must confirm the terminal
prognosis, that the requesting person
is mentally capable of making their own
medical decisions and is physically able
to self- ingest the medication, the person
must make two oral requests for the
medication, as well as a written request
witnessed by two people who can confirm
the person is voluntarily making the
request.
9
With the New Jersey legislation passing in
2019, these represent the most current best
practices for safeguards for assisted suicide laws
in the United States.
Are There Problems with
TheseSafeguards?
There are many ways that provisions of safeguard
provisions in US assisted suicide laws are
inadequate, can be readily circumvented, or fail to
protect patients from pressure to end their lives.
Many experts have contributed important
analyses of this key issue. For example, as
documented by Drs. Herbert Hendin and
Kathleen Foley as early as 2008,
The Oregon law seems to require
reasonable safeguards regarding the care of
patients near the end of life, which include
presenting patients with the option for
palliative care; ensuring that patients are
competent to make end- of- life decisions
for themselves; limiting the procedure to
patients who are terminally ill; ensuring
the voluntariness of the request; obtaining
a second opinion on the case; requiring
the request to be persistent, i.e., made
a second time after a two week interval;
encouraging the involvement of the next
The Danger of Assisted Suicide Laws 19
of kin; and requiring physicians to inform
OPHD [the Oregon Public Health Division]
of all cases in which they have written a
prescription for the purpose of assisted
suicide.
The evidence strongly suggests that these
safeguards are circumvented in ways that
are harmful to patients.
10
Following are
important ways that
asserted safeguards
under assisted suicide
laws can and have been disregarded and even
sidestepped entirely.
11
Assisted Suicide Instead
ofMedicalTreatment
The Oregon model assumes that if an eligible
patient doesn’t want assisted suicide, they can
receive medical treatment. But there is evidence
that patients, including
people with disabilities,
are being denied
treatment by insurers and
offered assisted suicide
instead, just as NCD
predicted in 1997.
12
When assisted suicide
is legalized in the context
of the US healthcare
system, it immediately
becomes the cheapest treatment. Direct coercion
is not necessary. If insurers deny, or even simply
delay, approval of expensive life- sustaining
treatment, patients can be steered toward
hastening their deaths— and sometimes insurers
help them to do so. For example, in 2008,
Barbara Wagner, a 64- year- old great- grandmother,
The evidence strongly suggests that
these safeguards are circumvented
in ways that are harmful to patients.
When assisted suicide is legalized...,
it immediately becomes the
cheapest treatment. Direct coercion
is not necessary. If insurers deny,
or even simply delay, approval of
expensive life-sustaining treatment,
patients can be steered toward
hastening their deaths...
was fighting recurring lung cancer. Her physician
prescribed Tarceva to extend her life. Studies
showed that the drug provided a 30 percent
increased survival rate for patients with advanced
lung cancer, and patients’ 1- year survival rate
increased by more than 45 percent. But the
Oregon Health Plan (Oregon’s Medicaid program)
sent Wagner a letter saying the Plan would not
cover the beneficial
chemotherapy treatment
“but... it would
cover... physician-
assisted suicide.”
13
Around the same
time, fellow Oregonian Randy Stroup was
prescribed Mitoxantrone as chemotherapy for
his prostate cancer. His oncologist said the
medication’s benefit has been shown to be “not
huge, but measurable”; while the drug may not
extend a patient’s life by very long, it helped
make the final months of life more bearable by
decreasing pain.
14
Yet
Stroup also received a
letter saying that the
Oregon Health Plan
would not cover his
treatment, but would pay
for the cost of, among
other things, his assisted
suicide.
15
These treatment
denials were based on
an Oregon Medicaid rule that denies surgery,
radiotherapy, and chemotherapy for patients
with less than a 5 percent expectation of 5- year
survival. H. Rex Greene, MD, former Medical
Director of the Dorothy E. Schneider Cancer
Center at Mills Health Center in San Mateo,
California and a former member of the AMA
20 National Council on Disability
Ethics Council, called this rule “an extreme
measure that would exclude most treatments
for cancers such as lung, stomach, esophagus,
and pancreas. Many important noncurative
treatments would fail the 5- percent/5- year
[criterion].”
16
These rules also presume that
all physician estimates for life expectancy are
always correct (see “Mistakes in Diagnosis and
Prognosis” below), and that a shortened life span
is not worth living.
Recent bills and laws to legalize assisted
suicide have included a newer provision to
prohibit an insurer from informing a patient in
the same communication, such as a letter, about
both a denial of treatment and the availability of
lethal drugs. For example, the 2015 California law
states: “Any [insurance carrier] communication
shall not include both the denial of treatment and
information as to the availability of aid-in- dying
drug coverage.”
17
Shortly after California’s assisted suicide
law went into effect in 2016, Stephanie Packer,
a mother of four and a cancer patient, was
denied her previously approved chemotherapy
treatment, but offered low- cost suicide pills by
her insurer by phone instead.
18
About a year
later, Dr. Brian Callister, associate professor
of internal medicine at the University of
Nevada, said he tried to transfer two patients
to California and Oregon for procedures not
performed at his hospital. The patients were
not terminal, but “would have become terminal
without the procedures.” Representatives
from the two patients’ insurance companies
denied both transfer requests in separate
phone calls. The insurance medical directors
told Callister they would cover neither the
procedures nor the transfers, but asked if he’d
considered assisted suicide for his patients,
though Callister did nothing to prompt such a
suggestion.
19
Mistakes in Diagnosis and Prognosis
Assisted suicide laws assume that doctors can
estimate whether or not a patient diagnosed as
terminally ill will die within 6 months. Actually, it
is common for medical prognoses of a short life
expectancy to be wrong. “Terminal Uncertainty,”
a 2009 article in the Seattle Weekly, summarized
a number of studies illustrating this problem and
the reasons for it.
20
The personal experiences of this problem are
also noteworthy. For example, Jeanette Hall of
Oregon was diagnosed with cancer in 2000 and
told she had 6 months to a year to live. She knew
about the assisted suicide law, and asked her
doctor about it, because she didn’t want to suffer.
Her doctor encouraged her not to give up, and
she decided to fight the disease. She underwent
chemotherapy and radiation. Eleven years later,
she wrote, “I am so happy to be alive! If my
doctor had believed in assisted suicide, I would
be dead.... Assisted suicide should not be
legal.”
21
As of this writing in 2019, Jeanette Hall
is alive and doing well, 19 years after her terminal
diagnosis.
22
In another example, disability rights advocate
Anita Cameron, Director of Minority Outreach
for Not Dead Yet, testified against an assisted
suicide bill in New York, regarding her mother,
Alice Bozeman. Cameron stated, “In June 2009,
while living in Washington State, my mother
was determined to be in the final stages of
Chronic Obstructive Pulmonary Disease and
placed in hospice. Two months later, I was told
that her body had begun the process of dying.
My mother wanted to go home to Colorado to
die, so the arrangements were made. A funny
The Danger of Assisted Suicide Laws 21
thing happened, though. Once she got there, her
health began to improve! Almost 8 years later,
she is still alive, lives in her own home in the
community and is reasonably active.”
23
In a final example, Laurie Hoirup, a California
woman with a life- long significant disability of
spinal muscular atrophy, survived by decades
several terminal prognoses given to her by
physicians over the course of her life, including
one that she would never reach adulthood. She
was a devoted wife, mother, and grandmother,
served as director of a center for independent
living and as chief deputy director of the State
Council on Developmental Disabilities, and was
apublished author. She was an active disability
advocate, including
offering testimony on
several occasions against
California assisted suicide
bills. She was the acting
head of the Association
of California State
Employees with
Disabilities. Hoirup finally
died at the age of 60 from accidental causes.
24
Her situation is illustrative and not unusual in the
disability community.
Faulty prognoses pose considerable danger
to people with new or progressive disabilities or
diseases, who may often be misdiagnosed as
terminally ill, but who, like Laurie Hoirup, could
potentially outlive these prognoses by years or
even decades. Research overwhelmingly shows
that people with new disabilities frequently go
through initial despondency and suicidal feelings,
but later adapt well and find great satisfaction
in their lives.
25
However, adaptation takes
considerably longer than the mere 15- day waiting
period required by Oregon- model assisted
Research overwhelmingly shows
that people with new disabilities
frequently go through initial
despondency and suicidal feelings,
but later adapt well and find great
satisfaction in their lives.
suicide laws. During an initial period after a new
disability, and before one learns that a disability
does not preclude a good quality of life, it can be
too easy, where assisted suicide is legal, to make
an irrevocable choice to die.
A counterexample was Dr. Richard Radtke, a
well- known academic oceanographer in Hawaii
for many years. Dr. Radtke had a very disabling
form of muscular sclerosis for more than
35years. In the early period after his diagnosis,
with an extremely limiting disability, doctors
often misclassified him as terminally ill, and he
experienced severe depression for 2 years. Had
the option for assisted suicide been available
at that time, he later acknowledged that he
would have chosen it
and died many years
earlier. Instead, Radtke
went on to a successful
academic career, and
was a happily married
father. After his
retirement, he served as
president of a charitable
foundation, and was grateful for the length and
scope of his life, until he finally died of natural
causes in 2012.
26
Further, regarding mistakes in diagnosis and
prognosis, the definition of “terminal” in Oregon
model laws only require two doctors’ estimates
that the patient will die within 6 months. There
is no requirement that the doctors consider the
likely impact of medical treatment, counseling,
and other supports on survival. For example, a
successful adaptation may necessitate referral to
state and community resources, such as social
workers, VA benefits, assistive technology, or
grants to create an accessible home. Adaptation
may also require counseling or antidepressant
22 National Council on Disability
medication. Yet referrals to services, and to
supportive counseling, are not included as
safeguards in assisted suicide laws.
Also, while terminal predictions of some
conditions, such as some cancers, are fairly well
established 1 or 2 months before death, this is
far less true 6 months out, as the law provides—
and is even less true for other diseases.
27
Depression and Demoralization
People with the disability of depression are
subject to harm where assisted suicide is legal.
Yet the law’s supporters frequently suggest
that, as a key safeguard, depressed people are
ineligible for assisted suicide.
28
Michael Freeland
of Oregon was a case
study of the potential
for harm. With his
permission, his case was
extensively documented
by Dr.Gregory Hamilton,
a Distinguished Fellow of
the American Psychiatric
Association. This
summary of Michael
Freeland’s story is
excerpted from Hamilton’s documentation:
29
At age 62, Michael Freeland had a 43- year
medical history of significant depression
and suicide attempts. After receiving
a diagnosis of terminal lung cancer, he
requested assisted suicide. Dr. Peter
Reagan, an assisted suicide advocate
who was associated with the group
Compassion in Dying (later renamed
Compassion & Choices), a leading pro-
assisted suicide organization, prescribed
[T]he definition of “terminal” in
Oregon model laws only require
two doctors’ estimates that the
patient will die within 6 months.
There is no requirement that the
doctors consider the likely impact of
medical treatment, counseling, and
other supports on survival.
lethal drugs to Michael Freeland without
even a cursory psychological evaluation.
Reagan commented that he did not think
such a consultation would be “necessary”
for Mr.Freeland, according to Freeland’s
daughter, who accompanied him to an
appointment.
Freeland then made a telephone call to
Physicians for Compassionate Care (PCC),
a medical group dedicated to improving
the care of seriously ill people without
resorting to assisted suicide. The call was
answered by a PCC volunteer who was
trained in counseling people with serious
illness. With encouragement from a doctor
recommended
by PCC, Freeland
underwent
chemotherapy and
radiation treatment,
which alleviated his
cancer symptoms
significantly. PCC
volunteers arranged
for him to receive
adequate pain care,
other appropriate medication, and 24- hour
attendant services. A PCC volunteer stayed
in touch with him to offer encouragement,
as did some old friends, who began to visit
him daily. He also received assistance to
resolve other health and personal problems.
With this multifaceted assistance, his
suffering abated, as did his wish to take
lethal drugs. He was able to fully reconcile
with his daughter, who had been estranged
from him during certain periods. In the
end, he lived 2 years post- diagnosis; he
eventually died of naturalcauses.
The Danger of Assisted Suicide Laws 23
What happened to Michael Freeland highlights
parts of the complex web of problems for people
with depression and demoralization under
assisted suicide laws.
First, the work of PCC with Michael
Freeland illustrates what Dr. Herbert Hendin,
an international expert on suicide intervention,
stated in Congressional testimony:
A request for assisted suicide is... usually
made with as much ambivalence as are
most suicide attempts. If the doctor does
not recognize that ambivalence as well as
the anxiety and depression that underlie the
patient’s request for death, the patient may
become trapped by that request and die in a
state of unrecognized
terror....
Patients who request
euthanasia are
usually asking in the
strongest way they
know for mental and
physical relief from suffering. When that
request is made to a caring, sensitive,
and knowledgeable physician who can
address their fear, relieve their suffering,
and assure them that he or she will remain
with them to the end, most patients no
longer want to die and are grateful for the
time remaining to them. Advances in our
knowledge of palliative care in the past
twenty years make clear that humane care
for the terminally ill does not require us to
legalize assisted suicide and euthanasia.
Study has shown that the more physicians
know about palliative care, the less apt they
are to favor legalizing assisted suicide and
“Study has shown that the more
physicians know about palliative
care, the less apt they are to favor
legalizing assisted suicide and
euthanasia.”
euthanasia. Our challenge is to bring that
knowledge and that care to all patients who
are terminally ill.
30
Thus, the challenge for doctors is to find out
what is behind the patient’s request to hasten
death, and address it. Yet, where assisted
suicide is legal, such a request begins a legally
sanctioned process. The depression remains
undiagnosed, and the only treatment consists of
a lethal prescription.
31
Another significant concern is assisted suicide
laws’ very limited requirement that the attending
physician must inform the patient of alternative
options, including “comfort care, hospice care,
palliative care, and
pain control”;
32
but no
physician or other party
is required to actually
provide the alternative
treatments, services,
and programs. And
nonmedical supports,
such as long- term services and supports (LTSS),
including home health care and assistance,
as well as counseling, may be even more
important— though many doctors do not have
knowledge of such services and supports to a
degree that allows them to fully inform people
requesting lethal drugs.
The 1997 NCD statement addressed the
major gap between informing the patient of
alternative options and those alternatives actually
being available and provided:
... In proposals to legalize assisted suicide,
proponents are sometimes willing to agree
that a decision to choose suicide must be
24 National Council on Disability
preceded by a full explanation of the
programs, resources, and options available
to assist the patient if he or she does not
decide to pursue suicide.
33
Many people with disabilities find this to be
a very shallow promise when they know
that all too often the
programs are too
few, the resources
are too limited, and
the options... often
nonexistent. Society
should not be ready
to give up on the
lives of its citizens
with disabilities until it has made real and
persistent efforts to give these citizens a
fairand equal chance to achieve a
meaningful life.
34
These unmet support
needs impact people
with terminal illness
aswell.
As mentioned
above, additional factors
complicate the situation
of depression in the
context of assisted
suicide. Though assisted
suicide requests
from people with terminal illness, like most
suicide requests, are usually based on fear and
depression,
35
Oregon’s statistics show that,
for example, in 2017, only 3.5 percent of those
who reportedly died under the Oregon law
were referred by the prescribing doctor for a
psychological evaluation before a prescription
“Society should not be ready to give
up on the lives of its citizens with
disabilities until it has made real
and persistent efforts to give these
citizens a fair and equal chance to
achieve a meaningful life.”
Oregon’s statistics show that... in
2017, only 3.5 percent of those who
reportedly died under the Oregon
law were referred by the prescribing
doctor for a psychological
evaluation before a prescription for
lethal drugs was written. In 2018, it
was 1.8 percent.
for lethal drugs was written.
36
In 2018, it was
1.8percent.
37
Some other states refer even fewer
people. In Colorado, only 1 out of the reported
69people (1.4 percent) was so referred.
38
Moreover, only 6 percent of Oregon
psychiatrists were confident they could diagnose
depression after one
visit, according to one
study.
39
Yet the definition
in the Oregon assisted
suicide law of psychiatric
“counseling” permits
only one visit. And
another study showed
that primary care
physicians are generally not experts in diagnosing
depression at all.
40
Another key factor, poorly understood, is
that people with depression can, in fact, receive
lethal drugs under assisted suicide laws, because
such patients are still
technically eligible as
long as they are deemed
legally competent;
that is, “competent
and not suffering
from a psychiatric or
psychological disorder
or depression causing
impaired judgment.”
41
[Emphasis added.] Thus,
patients with depression may be considered
legally competent to decide to end their
lives merely because the depression doesn’t
impair their legal competency. As Hendin and
Foley pointed out, “Reducing the psychiatric
consultation to the issue of competency ignores
all the other psychological factors that go into the
The Danger of Assisted Suicide Laws 25
request for assisted suicide.”
42
And these factors
can impair decision- making judgment, even if that
impairment of judgment does not quite meet the
threshold for legal incompetence.
A study in the British Medical Journal further
documented that people with depression are
receiving lethal drugs under assisted suicide
laws. As Dr. William Toffler wrote in the Wall
Street Journal Online in 2015,
43
A... British Medical Journal [study]
examined 58 Oregonians who sought
information on assisted suicide. Of them,
26% met the criteria for depressive
disorder, and 22% for anxiety disorder.
Three of the
depressed individuals
received and ingested
the lethal drugs, dying
within two months
of being interviewed.
The study’s authors
concluded that
Oregon’s law “may
not adequately protect all patients [with a
mental illness].”
44
And further, is the depression clinically
diagnosable, or subclinical? Recent research and
clinical work suggest that affective states such
as demoralization also pressure people toward
wanting to die, yet these states are even less
likely than clinical depression to be addressed.
Demoralization may be an unrecognized and
unaddressed precipitant of requests to die.
45
Lastly, given the history of forced treatment
and institutionalization that psychiatric survivors
have experienced, it is important to be clear
that, when discussing the serious matter of
[I]nternalized oppression; in other
words, being conditioned by
dominant cultural values to believe
that needing help is undignified,
less than fully human, and again,
burdensome to others.
depression in the context of assisted suicide
laws, the goal is not to force any treatment on
people who may have depression and/or who
may wish to hasten their deaths, including but
not limited to medication, institutionalization,
or hospitalization.
46
Rather, what’s needed is a
variety of available medical treatment options
as well as home and community- based service
options, ideally self- directed, from which the
individual genuinely benefits— similar to the range
of services that Dr. Greg Hamilton and his staff
assisted Michael Freeland to find.
Demoralization and Internalized
Oppression of People with Disabilities
Dr. Carol Gill, Ph.D.,
Professor Emerita in the
Department of Disability
and Human Development
at the University of
Illinois at Chicago, has
discussed how, for some
people with disabilities,
demoralization, similar
in some ways to depression, is one of the most
powerful, yet difficult, risk factors regarding
assisted suicide. Dr. Gill’s works discuss
internalized oppression; in other words, being
conditioned by dominant cultural values to believe
that needing help is undignified, less than fully
human, and again, burdensome to others. She
has asked, “How can one provide safeguards
forthat?”
47
For some people with disabilities,
demoralization or depression may be caused by
the long- term struggle against socially
constructed obstacles to one’s life goals, social
devaluation of disability, social isolation, financial
concerns, and lack of support to make life
26 National Council on Disability
meaningful. Further, feeling like a burden is a
potent risk factor for demoralization. According
to Dr. Gill, unfortunately, the tendency to equate
disability with burdensomeness is pervasive
in our society, placing people with disabilities
and seriously ill people at substantial risk of
demoralization.
48
This appears to be borne out in studies. For
example, an article on patient requests to hasten
death from the Archive of
Internal Medicine stated,
Symptoms and loss of
function can give rise
to dependency on
others, a situation that
was widely perceived
as intolerable... : “I’m inconveniencing,
I’m still inconveniencing other people who
look after me and stuff like that. I don’t want
to be like that. I wouldn’t enjoy it, I wouldn’t.
I wouldn’t. No. I’d
rather die.”
49
A related factor is the
absence of alternatives
for control in the face
of an advanced or
terminal condition.
Ifan individual’s only
alternatives to assisted suicide are nursing home
placement, burned- out family care, or suffering in
isolation, assisted suicide may seem preferable.
As the example of Michael Freeland illustrated,
no current assisted suicide law requires that
resources be made available for real alternatives,
including advocacy to help individuals understand
that they deserve, and can have, better options
than death.
If an individual’s only alternatives to
assisted suicide are nursing home
placement, burned-out family care,
or suffering in isolation, assisted
suicide may seem preferable.
“Shopping” for doctors is part of
the US healthcare system, and
an important right, though in the
context of assisted suicide, it creates
an opportunity for sidestepping
safeguards in the law.
Doctor Shopping
US assisted suicide laws allow physicians to
prescribe lethal drugs to patients who meet
certain legal criteria relating to terminal illness
and with the agreement of a second doctor.
Ifthe first doctor believes legal criteria have not
been met and denies a patient’s request for lethal
drugs, patients may continue to seek additional
physicians until they find
one who will obtain a
colleague’s concurrence
and prescribe a lethal
dose.
And if heirs, family
members, or caregivers
are pushing people with
disabilities, terminal illness, or chronic illness
toward assisted suicide, but the patients’ primary
care physician refuses the request, they, too, can
seek additional physicians until they find one who
will grant it. “Shopping” for doctors is part of the
US healthcare system,
and an important right,
though in the context
of assisted suicide, it
creates an opportunity for
sidestepping safeguards
in the law.
One example is Kate
Cheney, who was age85
and experiencing early dementia when she died
by assisted suicide under Oregon’s law. Her own
physician had declined to provide a lethal
prescription. But her managed care provider then
found a second physician who ordered a
psychiatric evaluation, which found that Cheney
lacked “the very high level of capacity required to
weigh options about assisted suicide.” Cheney’s
request was again denied, and her daughter
The Danger of Assisted Suicide Laws 27
“became angry.” Another evaluation took place,
this time with a psychologist who insisted on
meeting Cheney alone. The psychologist deemed
Cheney competent while noting that her “choices
may be influenced by her family’s wishes and
herdaughter... may be somewhat coercive.”
Cheney soon took the lethal drugs and died.
50
The documented concerns about Cheney’s
dementia and a “somewhat coercive” adult
daughter were not sufficient to stop the assisted
suicide process, though either should have been
disqualifying.
There is evidence suggesting that a key role
is played by organizations that support assisted
suicide, which have
helped patients and
their families through
the assisted suicide
process, and which can
refer interested parties to
doctors who will tend to
approve such requests.
Compassion & Choices
(formerly known as the
Hemlock Society
51
) was
involved in 75 percent to 90 percent of Oregon’s
reported assisted suicides, according to their
own data, until they stopped releasing such
information to the public after 2008.
52
Family and Economic Pressures
Oregon and Washington State statistics, minimal
though they are, show a high rate of patients’
concern about being a burden on others.
53
Yet,
assisted suicide laws have no protections for
patients when financial or emotional pressures,
sometimes from family, distort patient choice.
Examples of economic pressures and abuse
include Linda Fleming and Thomas Middleton.
Compassion & Choices (formerly
known as the Hemlock Society) was
involved in 75 percent to 90percent
of Oregon’s reported assisted
suicides, according to their own data,
until they stopped releasing such
information to the public after 2008.
Linda Fleming, diagnosed with stage four
pancreatic cancer, was the first person to use
the Washington State assisted suicide law.
Despite the fact that she had financial problems,
had been unable to work due to a disability, and
was forced to declare bankruptcy, the Director
of Compassion & Choices of Washington said
that her situation presented “none of the red
flags” that might have given his group pause in
supporting her request for death.
54
Thomas Middleton was diagnosed with
amyotrophic lateral sclerosis (ALS),
55
moved
into the home of Tami Sawyer in July 2008, and
died by assisted suicide later that same month.
Middleton had named
Sawyer his estate trustee
and put his home in the
trust. Two days after
he died, Sawyer listed
the property for sale,
sold it, and deposited
the $90,000 proceeds
into her own personal
account, not Thomas
Middleton’s trust
account.
56
A federal investigation into real estate
fraud exposed this abuse. Sawyer was indicted
for first- degree criminal mistreatment and first-
degree aggravated theft, partly over criminal
mistreatment of Thomas Middleton.
Of those in Oregon who reportedly died from
ingesting a lethal dose of medication in 2018,
more than 9 out of 168 (7.3 percent) mentioned
“financial implications of treatment” as a
consideration.
57
As Dr. Carol Gill explains, not all of the
family- related pressures are malicious or even
explicit. As one example, supportive family
members can find it difficult to accept functional
Of those in Oregon who reportedly
died from ingesting a lethal dose
of medication in 2018, more than 9
out of 168 (7.3 percent) mentioned
“financial implications of treatment”
as a consideration.
28 National Council on Disability
Linda Fleming, diagnosed with stage four
pancreatic cancer, was the first person to use
the Washington State assisted suicide law.
Despite the fact that she had financial problems,
had been unable to work due to a disability, and
was forced to declare bankruptcy, the Director
of Compassion & Choices of Washington said
that her situation presented “none of the red
flags” that might have given his group pause in
supporting her request for death.
54
Thomas Middleton was diagnosed with
amyotrophic lateral sclerosis (ALS),
55
moved
into the home of Tami Sawyer in July 2008, and
died by assisted suicide later that same month.
Middleton had named
Sawyer his estate trustee
and put his home in the
trust. Two days after
he died, Sawyer listed
the property for sale,
sold it, and deposited
the $90,000 proceeds
into her own personal
account, not Thomas
Middleton’s trust
account.
56
A federal investigation into real estate
fraud exposed this abuse. Sawyer was indicted
for first- degree criminal mistreatment and first-
degree aggravated theft, partly over criminal
mistreatment of Thomas Middleton.
Of those in Oregon who reportedly died from
ingesting a lethal dose of medication in 2018,
more than 9 out of 168 (7.3 percent) mentioned
“financial implications of treatment” as a
consideration.
57
As Dr. Carol Gill explains, not all of the
family- related pressures are malicious or even
explicit. As one example, supportive family
members can find it difficult to accept functional
impairment in a loved one. The desire to end the
perceived suffering of a family member can seem
altruistic, but nonetheless, can have the effect of
pressuring the ill person to hasten their death.
Also, a worried family may be supportive, but
can still lead an ill family
member to feel pressure
toward an early exit
from life simply to avoid
high medical bills from
depleting scarce financial
resources. And further,
disability is associated
with suffering, even by
many loving family members. Consequently,
while family members may not express the idea
in such explicit terms, the notion that people with
disabilities are “better off dead” is a common
view that may further erode safeguards.
58
Good Faith
The Oregon law lists procedural steps for the
patient, doctors, and other participants, and then
provides broad immunity for everyone involved:
No person shall
be subject to civil
or criminal liability
or professional
disciplinary action
for participating in
good faith compliance with ORS 127.800 to
127.897. This includes being present when
a qualified patient takes the prescribed
medication to end his or her life in a
humane and dignified manner.
59
Thus, the Oregon model protects anyone,
including physicians, from all criminal and civil
Of those in Oregon who reportedly
died from ingesting a lethal dose
of medication in 2018, more than 9
out of 168 (7.3 percent) mentioned
“financial implications of treatment”
as a consideration.
It is virtually impossible to disprove
a claim of good faith, making
all other safeguards effectively
unenforceable.
liability if they provide lethal drugs based on a
“good faith” belief that statutory criteria are
met. Every other US assisted suicide law and
proposal includes a similar provision. As the NCD
2005 statement pointed out, this is the lowest
culpability standard
possible, even below that
of negligence, which is
the minimum standard
governing all other
physician duties.
60
This
same protection from
liability is also provided
to family members,
caregivers, and other associates of the patient,
regardless of their actions.
It is virtually impossible to disprove a claim of
good faith, making all other safeguards effectively
unenforceable. For example, the individual may
be depressed, or may be responding to coercion
from other people. But if everyone involved
claims they acted in a good faith belief that
all circumstances complied with the law, they
have no liability, since it is virtually impossible to
disprove a stated claim
of good faith, which is
merely a personal belief.
If the liability standard for
physicians under assisted
suicide laws were
negligence, as it is for all
other medical practices, then physicians might be
found negligent in these situations.
Physicians Hold
Disproportionate Power
Doctors are respected authority figures for
most people and can influence a patient just
by bringing up assisted suicide as a potential
The Danger of Assisted Suicide Laws 29
treatment, implicitly suggesting that it could be
appropriate for them.
As stated in the Journal of the American
Medical Association,
Physicians can influence patients, even in
ways they may not consciously appreciate.
Patients seeking physician- assisted suicide
may seek validation to end their lives.
Indeed, studies have shown that socially
isolated vulnerable individuals seek social
support and contact through visits with
their physicians. [And] physicians can
influence patients based on the physician’s
own potential fears of
death and disability.
61
The NCD 1997
position statement
addressed prejudice by
healthcare professionals
in detail:
People with
disabilities’ lives
are frequently
viewed as valueless by others, including
members of the medical profession. People
with disabilities are often harassed and
coerced to end their lives when faced
with life- threatening conditions, even if
the conditions are imminently treatable;
others have had their lives involuntarily
terminated by medical personnel. These
practices manifest blatant prejudice and
are a virulent form of the discrimination
that the Americans with Disabilities Act
and other laws condemn. Legal and
medical authorities should denounce and
[R]esearch showed that health
professionals who had negative
assessments of quality of life for
people with disabilities were less
likely to offer, or even know much
about, options to extend and
enhance life with a disability, such
as noninvasive ventilation.
prohibit any attempt to pressure, harass,
or coerce any individual to shorten her or
his life; they should certainly proscribe
any action to terminate an individual’s life
taken without that person’s full, voluntary,
and informed consent, whether it be called
“suicide,” “mercy killing,” “letting nature
take its course,” or some other euphemistic
term. And certainly there should be official
condemnation and cessation of practices
by which people with disabilities are
pressured to sign “Do Not Resuscitate”
consent forms, or such forms are hidden
within a stack of admission and consent
papers in the hope
that [patients] will sign
them without paying
attention to what is
being signed.
62
As mentioned above,
health professionals, in
general, receive little
training about life with
a disability, or disability
resources. Most know
little more than the general public about daily life
with a disability and options for supports. Thus,
they don’t know how to recognize and intervene
when patients experience disability- related
demoralization as described above.
63
Even with benign intentions, physicians
generally dispense only medical facts: diagnosis,
prognosis, and medical treatment options. Very
rarely can they address nonmedical, quality- of- life
interventions that are often much more important
for managing an advanced chronic or terminal
condition and making continued life desirable.
For example, John Bach’s research showed
30 National Council on Disability
that health professionals who had negative
assessments of quality of life for people with
disabilities were less likely to offer, or even know
much about, options to extend and enhance life
with a disability, such as noninvasive ventilation.
64
Further, “incurable” is often assumed to
mean unbearable or hopeless. Because most
disabilities are not curable, and disability is
equated with suffering, the public and many
health professionals conclude that life with
disability is hopeless.
65
Thus, a patient with a
pre- existing physical or sensory disability might
be perceived differently than someone who is not
already disabled, but is diagnosed with a terminal
disease such as cancer, in that physicians might
allow the disability to be a reason to more easily
accept that the patient’s request for death is
valid, due to their a perception that living with a
disability is not worthwhile.
All of this can contribute to further erosion
of the supposed safeguards in the operation of
assisted suicide, once it is legalized.
Safeguards Are Gradually Diminishing
Assisted suicide proposals tend to promise
strict safeguards that will, in theory, avoid any
dangers or problems. But once passed, the
restrictions tend to be ineffective or inadequate,
as shown in this chapter. Chapter2 will discuss
how requirements for data collection have been
decreased in recent statutes. And Chapter4 will
show how rules governing assisted suicide are
being loosened, and how new proposals may
reduce them further.
The Danger of Assisted Suicide Laws 31
32 National Council on Disability
Chapter2: Lack of Data Collection, Oversight,
andInvestigation of Mistakes and Abuse
T
his chapter addresses how assisted
suicide laws and proposals in the United
States address data collection and
analysis. Do they provide adequate oversight? Do
they establish a way to investigate mistakes and
abuse? Do their data reveal anything useful? And
what else is needed?
Minimal Data and Scant Oversight
Many key questions
about assisted suicide
laws cannot be answered
because of the substantial
lack of data, including
both quantitative and
qualitative data, on the
medical and demographic
profiles of people who
have sought and used
assisted suicide. This is
not due merely to the
lack of research, but because of the very strict
privacy and confidentiality requirements that are
structured into every assisted suicide law to date.
As a Michigan Law Review article stated
under the heading “Excessive Secrecy,”
OPHD has focused more on patient-
doctor confidentiality than on monitoring
compliance or abuse. The agency has
developed confidentiality measures unique
to physician- assisted suicide which appear
to be unnecessarily secretive and limit the
potential for thorough research into the
dimensions and context of this practice as
it unfolds.... Medical standards require
openness about facts, research data, and
records to assess the appropriateness of
treatment. The anonymity and secrecy
about physician
practice of assisted
suicide makes such
an assessment
impossible. If
physician- assisted
suicide is to be
part of the medical
treatment for terminal
illness, why are
existing patient- doctor
confidentiality rules
not sufficient... ? Restricting access
to information about the indications for
assisted suicide, patient data, radiologic
documentation, and specific drug therapy
limits the opportunity to establish an
objective standard of care, provides
excessive protection to the physician and,
in the name of confidentiality, leaves the
patient vulnerable.
66
Medical standards require
openness about facts, research
data, and records to assess the
appropriateness of treatment.
The anonymity and secrecy about
physician practice of assisted
suicide makes such an assessment
impossible.
The Danger of Assisted Suicide Laws 33
Consequently, it is difficult to understand the
personal, financial, medical, and psychological
circumstances of people who request and
useassisted suicide. If it were available, this
information would enable all parties to better
interpret why and how assisted suicide is carried
out and what interventions or information might
improve the options of doctors, patients, and
theirfamilies. It would
enable the public to
betterunderstand if there
have been any medical
complications during
administration of assisted
suicide drugs, as well as
other problems associated
with this practice.
As the NCD 2005 statement pointed out,
and as the annual brief statistical reports from
Oregon make clear, the state has not, and
in fact, cannot assess the extent of nonreporting
or noncompliance with the law’s purported
safeguards. The Oregon
Health Authority reports
are based on forms filed
with the state by the
physicians who prescribe
lethal doses and the
pharmacies that dispense
the drugs. As the early
reports admitted:
Underreporting and noncompliance is...
difficult to assess because of possible
repercussions for noncompliant physicians
reporting to the division.
67
This odd justification seems to be stating
that doctors are unlikely to report their own lack
[A]s the annual brief statistical
reports from Oregon make clear,
the state has not, and in fact, cannot
assess the extent of nonreporting
or noncompliance with the law's
purported safeguards...
Similarly, the state has no way for
the public, family members, or
other healthcare professionals to
report suspected problems, nor
even a means of investigating
mistakes and abuse.
of compliance with the law. It also implies that
physicians may circumvent safeguards or not
follow procedures, including mandated reports,
because authorities refrain from providing any
oversight or follow- up. Given that physicians are
already protected by the law and cannot be held
negligent, this is especially remarkable.
Similarly, the state has no way for the public,
family members, or other
healthcare professionals
to report suspected
problems, nor even a
means of investigating
mistakes and abuse. As
the Oregon Department
of Health and Human
Services stated:
We are not given the resources to
investigate [assisted suicide cases] and not
only do we not have the resources to do it,
but we do not have any legal authority to
insert ourselves.
68
One consequence,
which applies to all
assisted suicide laws to
date, is that important
questions go unasked,
such as why some
doctors refuse to assist
patients in suicide. Doctors who said “no” may
have concluded that a patient did not meet legal
requirements— essential information to evaluate
a law’s outcomes. Further, none of these states
interview family members or friends to learn
about the physical and emotional status of those
who died, nor do they interview or collect any
information from patients prior to their deaths.
69
34 National Council on Disability
Another significant problem with data
collection is the secrecy created by a common
provision in assisted suicide laws for the last
decade concerning death certificates, and the
ability of physicians to falsify them so they do
not show assisted suicide as the actual cause
of death. This provision in Connecticut bills in
2015 and 2019 prompted that State’s Division of
Criminal Justice to enter the debate. While not
taking a position on the overall bill both times, the
Division asked the legislature for deletion of this
provision:
Section9(b) effectively mandates the
falsification of death
certificates under
certain circumstances.
It states: “The person
signing the qualified
patient’s death
certificate shall list the
underlying terminal
illness as the cause of
death.” This is simply
not the case; the
actual cause of death
would be the medication taken by or given
to the patient. This language contradicts the
death certificate form itself, which states for
the person making the certification: “On the
basis of examination, and/or investigation,
in my opinion, death occurred at the time,
date, and place, and due to the cause(s)
and manner stated.”... The practical
problem for the criminal justice system and
the courts will be confronting a potential
Murder prosecution where the cause of
death is not accurately reported on the
death certificate.
70
As the Oregon Department of
Health and Human Services stated:
“We are not given the resources to
investigate [assisted suicide cases]
and not only do we not have the
resources to do it, but we do not
have any legal authority to insert
ourselves.”
Daniel Callahan, Senior Research Scholar and
President Emeritus of the Hastings Center, has
written:
In the case of Oregon, we have been
assured that all is well, that no abuses are
occurring.... If you know, just know, there
are no abuses, why bother? Regulations of
that kind, protected from public scrutiny,
but with the ring of authority and oversight,
are a Potemkin village form of regulatory
obfuscation. They look good, sound good,
feel good, but have nothing behind them.
71
As Maryland state
Senator Bob Cassilly
wrote in the Baltimore
Sun in 2019:
The [Maryland]
doctor assisted
suicide bill... gives
undue influence
to the health
care industry and
prevents even close
family members from uncovering the facts
or taking any action to protect a loved one’s
interests.
Consider a possible scenario of a brother,
George, who wants to find out why his
sister, June, recently diagnosed with
cancer, was unexpectedly found dead
on her kitchen floor only days after her
diagnosis. June’s death certificate would
simply indicate that she died of her illness
many months earlier than doctors had first
advised, making no mention of the poison
she ingested. George would have no access
The Danger of Assisted Suicide Laws 35
to any records of the conversations June
had with the doctor provided by June’s
insurance company.
72
George would never
know that June’s doctor told her that she
could elect expensive treatment, paid in
part by her insurer, to extend June’s life but
that in doing so June would likely become
a considerable burden on her family and
friends. George would never know that in
June’s distraught mental state her doctor
advised that she could avoid becoming a
burden by taking... very inexpensive pill[s],
paid for by her insurance company, to end
her life. George would never know that,
despite June’s considerable mental anguish
over the decision to take her own life, she
was never provided access to a mental
health counselor nor did any outside doctor
review the terminal diagnosis. George
would also never know that all of those who
influenced June’s decision to end her life
were employed by the same health care
provider who stood to gain financially from
June’s quick death: the advising doctor,
the doctor tasked to prescribe the poison,
and two hospital staff who witnessed
June sign the written consent. If George
was sufficiently alarmed and tried to file
a lawsuit, he would find that he could not
obtain any of the relevant medical records
and that the hospital and doctors are
immune from suit so long as George cannot
prove they acted in bad faith, an impossible
burden given that all of the facts rest with
June and the records George cannot obtain.
73
Proponents of assisted suicide frequently
state that no abuses, problems, or even medical
complications have ever occurred under these
laws. For example, current and former governors
of Hawai’i stated:
With more than 30 years combined of
practice in the authorized states, there has
not been a single instance of documented
abuse of medical aid in dying. Two decades
of rigorously observed and documented
experience in Oregon shows us the law
has worked as intended, with none of the
problems opponents had predicted.
74
Given the lack of data collection and the
absence of transparency, one cannot turn to
official records to document such problems.
In fact, quite a few problems, complications,
and even abuses have been documented, by
either the media, patients and their families,
or other concerned watchdogs; some of these
are described throughout this report. The
Disability Rights Education & Defense Fund
(DREDF) compiled approximately 16 examples in
various categories, including “Doctor Shopping
Gets Around Any ‘Safeguards,’” “Depression,”
“Economic Pressures and Coercion,” “Self-
Administration,” “Deadly Mix Between Our
Broken Healthcare System and Assisted Suicide,”
“Breakdown in Rules Attendant to Changing the
Law,” “Medical Complications,” and “Impacts by
Doctors and Their Quality of Care.”
75
Rather than correcting any of these
fundamental problems, OPHD responded to
pressure from pro- assisted suicide advocates to
stop using the term “assisted suicide.” OPHD
had originally employed this term, commonly
used in the legal and medical literature, for
7years on its website and in its annual reports.
But Compassion & Choices, in the wake of
polling data that public support for assisted
36 National Council on Disability
suicide decreases if the word “suicide” appears,
successfully pressured OPHD in 2006 to switch
to more nebulous terms such as “persons who
use the Oregon Death with Dignity Act.” The
war over terminology for assisted suicide, which
persists to this day, traces back to these events.
76
Conclusions Regarding the Data
ThatIs Available
Even the minimal data provided by Oregon
demonstrates several important points. For one,
it shows that, except for the first year, people
whose illnesses did not result in death within
6months have received lethal prescriptions in
all 20 years the assisted suicide law has been in
effect.
77
Washington State reports comparable
results,
78
and no other states to date have made
this data public.
Further, reasons for
requesting assisted
suicide that sound
like a cry for help
with disability- related
concerns appear to be ignored. The top five
reasons doctors give for their patients’ assisted
suicide requests are not pain or fear of future
pain— that alone is noteworthy— but psychological
issues that are all- too- familiar to the disability
community: “loss of autonomy” (95.5percent),
“less able to engage in activities” (94.6 percent),
“loss of dignity” (87.4percent), “losing control of
bodily functions” (56.5percent), and “burden on
others” (51.9percent).
79
It should be noted that the “reasons” are not
directly gathered from the individuals themselves
but are gathered from proxies (their physicians)
after assisted suicides have already occurred. This
is a concerning source of potential error, without
any way to validate the reports. Moreover, the fact
[T]here is no way for authorities to
know whether the lethal dose was
self-administered and consensual.
that the reporting forms include these particular
check boxes to indicate patients’ reasons means
that these reasons were viewed as acceptable
from the beginning of the laws’ implementation.
Yet they are based on an uninformed analysis of
how to address disability- related issues.
80
And perhaps most importantly, the Oregon
data reveal that there is no required evidence
of consent or self- administration of lethal
drugs. In about half the reported cases, the
Oregon Health Authority reports state that no
healthcare provider was present at the time
of ingestion of the lethal drugs or at the time
of death.
81
This means there is no way for
authorities to know whether the lethal dose was
self- administered and consensual. Therefore,
although self- administration is touted as one of
the key “safeguards,”
82
in about half the cases,
there is no evidence of
consent. If the drugs
were, in some cases,
administered by others
without consent, no one would know. See more
about this key issue in Chapter4.
Trends in Data Collection Show
Decrease over Time
Possibly due to public discussion and debate over
what has been gleaned from the minimal data
under the Oregon law, the trend over time is to
collect and/or report even less data.
For example, certain data in states that
legalized assisted suicide more recently is
collected but not reported to the public. In
Oregon and Washington State, the first states
to legalize assisted suicide (Oregon in 1994
and Washington State in 2008), some general,
minimal data about a patient’s reason(s) for
The Danger of Assisted Suicide Laws 37
requesting lethal drugs is collected and reported
annually. Washington State’s 2017 Annual
Report, for example, stated that leading reasons
for requesting assisted suicide were losing
autonomy, being less able to engage in activities
that make life enjoyable, loss of dignity, and
being a burden on family, friends, and caregivers.
More than 50 percent of patients cited were
concerned about being a burden on others.
83
But in California, which legalized assisted suicide
in 2015, while this data is collected, it is not
required to be publicly reported— and the state
has not reported this information voluntarily, so it
remains unknown.
Another California example concerns a
provision in the law characterized by Rita Marker,
Executive Director of the Patients Rights Council,
as “extremely dangerous.”
“443.19. (a) The State Department of
Public Health shall collect and review the
information submitted... The information
collected shall be confidential and shall
be collected in a manner that protects the
privacy of the patient, the patient’s family,
and any medical provider or pharmacist
involved with the patient under the
provisions of this part. The information
shall not be disclosed, discoverable,
or compelled to be produced in any
civil, criminal, administrative, or other
proceeding.” [Emphasis added.]
The first sentence... would protect
the privacy of patients and individuals
participating in doctor- prescribed
suicide. However, the second sentence
(highlighted in bold) is new. [It] could
protect any person who causes a
vulnerable patient’s death, even if the
person’s actions were in violation of
[California’s] End of Life Option Act.
For example, if a family member finds out
that someone coerced a loved one into
signing the written assisted- suicide request
and then forced the loved one to take the
lethal drugs after [they] were mailed to
the patient’s home, [this] provision would
actually prohibit any investigation into the
loved one’s death.
This new wording sets the stage for
massive patient abuse and complete
protection for those engaged in criminal
activity that culminates in a patient’s
death. Absolutely no information related
to the patient’s death could be disclosed
to law enforcement or any other
investigatingbody.
Nothing in any other state proposal [until
this point in time] has ever contained this
type of language.
84
The later Hawaii law (2018) contains a similar
provision.
85
38 National Council on Disability
Chapter3: How Are Assisted Suicide Laws Viewed
byDisability Organizations?
T
he disability community is highly diverse,
and not every disability group is actively
speaking out about assisted suicide laws,
or even working on the issue. However, every
prominent national disability organization that
takes any position on assisted suicide laws is
in opposition. Many of these well- established
organizations are predominantly managed and
directed by people with disabilities, widely
respected for their advocacy, and reflect
diverse disability leadership. Included are
the National Council on Independent Living,
The Arc of the United States, the American
Association of People with Disabilities, United
Spinal Association, Not Dead Yet, ADAPT, the
Association of Programs for Rural Independent
Living, and the DREDF. (See a complete list
of national organizations that oppose assisted
suicide laws.
86
) Research has not revealed any
examples of national disability organizations—
whether or not they are led by people with
disabilities— that are in favor of such laws.
However, there is also a wide range of disability
organizations that do not take any position on
assisted suicide laws, particularly if it is not a
priority for their work.
As with many issues and social movements,
various individuals are not always in complete
unison. Some people with disabilities do support
these laws in whole or in part, but their views
have not been echoed by established national
disability rights organizations.
The Danger of Assisted Suicide Laws 39
40 National Council on Disability
Chapter4: Recent Issues and Events: Bringing
theNCD Position Up to Date
O
ver the last 25 years, there has been
avigorous policy debate in state after
state over proposed assisted suicide
laws. In many states, multiconstituency coalitions
have come together to oppose assisted suicide
laws that include disability advocates, physicians,
faith- based organizations, and other groups.
Far more state proposals are rejected than
passed, often due to education and advocacy
efforts about the dangers and harms of assisted
suicide laws by the coalitions described above.
According to the Patients
Rights Council,
[S]ince Oregon
legalized assisted
suicide in 1994,
many states have
rejected assisted-
suicide measures,
some multiple times. Since January 1994
[until] the end of January 2019, there have
been 269 legislative proposals in more than
39states... Yet, over and over again, bills
were either defeated, tabled for the session,
withdrawn by sponsors, or languished with
no action taken.
87
For example, in 2018, assisted suicide
proposals in 19 states were defeated, while only
Hawaii’s passed. In 2017, proposals in 27 states
were defeated; none passed. A complete listing
of US assisted suicide proposals is maintained by
the Patients Rights Council.
88
Several key evolving issues in the assisted
suicide debate were raised in a 2015 California
court decision (brought before assisted suicide
was legalized there). The judge held that “Most
states make it a crime to assist suicide.... They
are long standing expressions of the States’
commitment to the protection and preservation
of all human life.” (Glucksberg, at p.710.) The
decision continued,
Far more state proposals are
rejected than passed, often due
to education and advocacy efforts
about the dangers and harms
of assisted suicide laws bythe
coalitions described above.
The Danger of Assisted Suicide Laws 41
It is one thing to
take one’s own life,
but quite another
to allow a third
person assisting
in that suicide to
be immune from
investigation by the coroner or law
enforcement agencies.
In such a case, the state has a legitimate
competing interest in protecting society
against abuses.... It is the interest of the
state to... protect the lives of those who
wish to live... (Donaldson, at p. 1622)
Since “Aid in Dying” is quicker and less
expensive [than other treatment options],
there is a much greater potential for its abuse,
e.g., greedy heirs- in- waiting, cost containment
strategies, impulse decision- making, etc....
Further, “Aid in Dying” creates the possible
scenario of someone taking his life based
upon an erroneous diagnosis of a terminal
illness, which was, in fact, a misdiagnosis...
After all, doctors are not infallible.
Furthermore, “Aid in Dying”... could have
the unintended consequence of causing
people who are not terminally ill... to
view suicide as an option in their unhappy
life. For example,... a bullied transgender
child, or a heartsick teenaged girl whose
first boyfriend just broke up with her,
questioning whether
life is really worth
living. These children
may be more apt
to commit suicide
in a society where
the terminally ill are
routinely opting for
it....” (Donaldson,
atp. 1623.)
89
Sense of Congress Resolution
In the US House of Representatives in 2017,
Congressman Brad Wenstrup introduced
H.R. Con. Res. 80, “Expressing the sense of
the Congress that assisted suicide... puts
everyone, including those most vulnerable,
at risk of deadly harm....” It garnered both
Democrat and Republican cosponsors in equal
numbers.
90
NCD wrote a letter in support of
this resolution.
Other key evolving issues and noteworthy
events in the assisted suicide debate include the
following examples.
[W]here assisted suicide is legal, an
heir or abusive caregiver can steer
someone toward it, witness the
request, pick up the lethal dose, and
even, in the end, give the drug—
because when the lethal agents
are administered, no witnesses are
required.
The Risks of Abuse
Disability abuse
91
and elder abuse
92
are rising
problems. NCD has recently released several
reports documenting such abuse. Elder law
attorney Margaret Dore has written that the
Washington State assisted suicide law “invites
coercion.” According to her analysis, where
assisted suicide is legal, an heir or abusive
caregiver can steer someone toward it, witness
the request, pick up the lethal dose, and even,
in the end, give the drug— because when the
lethal agents are administered, no witnesses are
required.
93
This surprising fact,
a part of every assisted
suicide proposal and law,
was underscored by the
Patients Rights Council in
discussing a recent bill:
Patients would have
no protection once
the prescription is
filled. The patient’s
health care provider
is not required to be present when the
patient takes the lethal drugs. There is no
way to know who, if anyone, is present or
what actually takes place leading up to the
patient’s death. The patient could be tricked
or forced into taking the overdose. And no
one would ever know. Why aren’t there any
protections at the most important part of
the process?
94
As John Kelly, a leading disability rights
advocate and writer working against assisted
suicide laws, and the Director of Second
42 National Council on Disability
Thoughts Massachusetts, pointed out, “For there
to be any real safeguard against abuse, officials
would need to investigate the home situation.”
95
However, as discussed in Chapter2, no
assisted suicide laws to date authorize any type
of investigation of alleged abuse, nor do they
even include a means for the public to report
suspected mistreatment.
Loosening
oftheRules
Proposals to legalize
assisted suicide are
gradually growing less
and less protective of
public safety, and thus, their legalization would
pose increased dangers. Loosening of the rules
is occurring in a number of different ways.
Examples include:
Eligibility Determinations. The definition
of “terminal” in most assisted suicide
statutes requires that two doctors
predict that the person will die within
6 months. Many conditions will or may
become terminal if certain medications
or routine treatments are discontinued.
The list of conditions found eligible for
assisted suicide in Oregon, according
to annual reports, has grown over the
years to include: neurological disease,
respiratorydisease, heart/circulatory
disease, infectious disease, gastrointestinal
disease, endocrine/metabolic disease
(e.g., diabetes), arthritis, arteritis,
sclerosis, stenosis, kidney failure, and
musculoskeletal system disorders.
96
But
people with many such conditions would
not die if properly treated.
[N]o assisted suicide laws to date
authorize any type of investigation
of alleged abuse, nor do they even
include a means for the public to
report suspected mistreatment.
As one advocate explained,
In legislation that we have seen to date,
it is far too easy to qualify for assisted
suicide. Most set the bar at anyone who,
with or without treatment, would have
six months to live. Using myself as an
example, if I were to stop managing my
diabetes, I would
easily meet this
standard. I am not
alone; this expansive
definition includes a
great many people
with disabilities who
will happily live for
Conditions Eligible for Assisted
Suicide in Oregon
Neurological disease
Respiratory disease
Heart/circulatory disease
Infectious disease
Gastrointestinal disease
Endocrine/metabolic disease (e.g.,diabetes)
Arthritis
Arteritis
Sclerosis
Stenosis
Kidney failure
Musculoskeletal system disorders.
Note: People with many such conditions
would not die if properly treated.
The Danger of Assisted Suicide Laws 43
decades with proper treatment. This is
a definition which leaves people [with
disabilities] wide open to potential
abuse.
97
A recent Hawaii bill had no requirement
for a second doctor, often termed the
consulting physician, to confirm the
patient’s diagnosis or eligibility for assisted
suicide. All actions
could be carried out
by a single attending
physician. In the end,
this bill failed to pass,
though a bill passed
the following year
that did require a
consulting physician’s
concurrence.
98
Further,
as of this writing in 2019, an Oregon bill
to broaden its law, HB 2232, would define
terminal disease as “a disease that will,
within reasonable medical judgment,
produce or substantially contribute to a
patient’s death.”
99
Almost anyone with
a chronic condition
or disability would
be eligible under that
definition.
Authority to
Prescribe Lethal
Drugs. Some recent assisted suicide
proposals would allow nonphysicians to
prescribe lethal drugs. For example, a 2019
bill in New Mexico would have allowed
a “health care provider,”
100
defined as a
physician, an osteopathic physician, a nurse
licensed in advanced practice, or a physician
[A]n Oregon bill to broaden
its law, HB 2232, would define
terminal disease as “a disease that
will, within reasonable medical
judgment, produce or substantially
contribute to a patient’s death.”
[A] recent bill in New York State
would make it possible for the
patient to receive the lethal drugs
within a day after the diagnosis of a
terminal illness is confirmed.
assistant to diagnose a patient’s terminal
disease and to prescribe the lethal drugs for
assisted suicide.
101
And the Hawaii law, as
originally proposed, would have permitted
advanced practice registered nurses, as well
as doctors, to be “attending provider[s]”
who could diagnose a patient’s terminal
disease and prescribe lethal drugs.
102
Waiting Periods.
The Oregon model
requires a waiting
period of 15 days after
lethal drugs are initially
requested. This has
been touted as a way
to allow considerations
of alternatives and
protect vulnerable
individuals. Yet some recent bills are moving
away from this protection. For example, a
recent bill in New York State would make it
possible for the patient to receive the lethal
drugs within a day after the diagnosis of
a terminal illness is
confirmed.
103
As of this
writing in 2019, a bill
in Oregon would also
create exceptions to
the waiting period.
104
People with
Depression. As of
thiswriting, an amendment to a Maryland
bill
105
would require psychiatric evaluations,
geared toward determining if a mental state
such as depression is causing impaired
judgment. Compassion & Choices issued
apress release calling this and other
amendments “excessive.”
106
In response,
44 National Council on Disability
five Maryland state senators from the
Democratic Party released a statement
saying, “By deeming mental health
evaluations as ‘excessive,’ Compassion
andChoices is saying that the success
ofthis flawed proposal is more important
than attempts to protect those [people]
whohave a mental illness. We are asking
that if you share OUR commitment to
mental health, please [contact] Committee
members... [to vote] NO on... Senate
Bill 311.”
107
[Emphasis in original.]
Expansion is most overt in the few countries
outside the United States
that permit assisted
suicide and other forms
of hastened death, such
as active euthanasia
(lethal injections
by doctors). These
countries include the
Netherlands, Belgium,
and Canada.
108
As Rita
Marker pointed out, “The
true relevance for the US
of developments in other countries is seeing how
fast this moves and how it’s promoted for those
who can’t even request it themselves.”
109
The
countries permitting this include the Netherlands,
Belgium, and Canada.
110
To illustrate these two consequences of
expansion, the Dutch example provides the
longest experience with assisted suicide in any
country. Although it remained technically illegal
until 2002, the Netherlands first began to legally
tolerate assisted suicide in the early 70s.
111
Today, active euthanasia has almost completely
replaced assisted suicide.
112
Dr. Herbert Hendin
[A]n amendment to a Maryland
bill would require psychiatric
evaluations, geared toward
determining if a mental state such
as depression is causing impaired
judgment. Compassion & Choices
issued a press release calling this
and other amendments “excessive.”
documented how assisted suicide and lethal
injections have become not the rare exception
but the rule for people with terminal illness in
the Netherlands. Hendin was one of only three
foreign observers given the opportunity to study
these medical practices in the Netherlands in
depth. He stated in Congressional testimony:
Over the past... decades, the
Netherlands has moved from assisted
suicide to euthanasia, from euthanasia
for the terminally ill to euthanasia for the
chronically ill, from euthanasia for physical
illness to euthanasia for psychological
distress, and from
voluntary euthanasia
to nonvoluntary and
involuntary euthanasia.
Once the Dutch
accepted assisted
suicide, it was not
possible legally or
morally to deny...
active... euthanasia
[lethal injections] to
those who could not
effect their own deaths. Nor could they
deny assisted suicide or euthanasia to the
chronically ill who have longer to suffer
than the terminally ill or to those who have
psychological pain not associated with
physical disease. To do so would [have been
seen as] a form of discrimination.
Involuntary euthanasia has been justified as
necessitated by the need to make decisions
for patients not competent to choose for
themselves.... The Remmelink report [the
Dutch government’s commissioned study of
the problem] revealed that in over
The Danger of Assisted Suicide Laws 45
1,000 cases, of the 130,000 deaths in the
Netherlands each year, physicians admitted
they actively caused or hastened death
without any request from the patient....
In[many] of these cases..., physicians
gave the patient’s impaired ability to
communicate as their justification for not
seeking consent.
113
Further on the subject of loosening the rules,
Hendin also testified,
Legal sanction creates a permissive
atmosphere that seems to foster not
taking the guidelines
too seriously. The
notion that...
American doctors...
would follow
guidelines if assisted
suicide were legalized
is not borne out by
the Dutch experience;
nor is it likely
given the failure of
American practitioners
of assisted suicide to follow elementary
safeguards in cases they have published.
114
Double Standard in Suicide
Prevention
Diane Coleman, president and founder of Not
Dead Yet, a grassroots disability organization
opposed to legalizing assisted suicide, developed
the important critique that the
public image of severe disability as a fate
worse than death... become[s] grounds
Before Oregon legalized assisted
suicide, its suicide rate was similar
to the national average. Yet by
2010, Oregon's suicide rate was
41percent above the national
average. In states overall, assisted
suicide laws are associated, on
average, with a 6 percent increase
in a state’s total suicide rate.
for carving out a deadly exception to
longstanding laws and public policies about
suicide [prevention] services.... Legalizing
assisted suicide means that some people
who say they want to die will receive
suicide intervention, while others will
receive suicide assistance. The difference
between these two groups of people will
be their health or disability status, leading to
a two- tiered system that results in death to
the socially devalued group.
115
Evidence of Suicide Contagion
Studies show an
increased rate of general
suicide in states where
assisted suicide is legal.
In Oregon, government
reports show a statistical
correlation between
assisted suicide under
the Oregon law and
an increase in other
suicides. Before Oregon
legalized assisted
suicide, its suicide rate
was similar to the national average. Yet by 2010,
Oregon’s suicide rate was 41 percent above the
national average.
116
In states overall, assisted suicide laws are
associated, on average, with a 6 percent increase
in a state’s total suiciderate.
117
Dr. Aaron Kheriaty, associate professor of
psychiatry and director of the medical ethics
program at the University of California at Irvine
School of Medicine, pointed out, “[Such] results
should not surprise anyone familiar with the
literature on the social contagion effects of
46 National Council on Disability
suicidal behavior. You don’t discourage suicide by
assisting suicide... [P]ublicized cases of suicide
can produce clusters of copycat cases, often
disproportionately affecting young people, who
frequently use the same method as the original
case.”
118
This dynamic, known as the Werther
Effect, was cited as a danger of assisted suicide
by Judge Gregory W. Pollack in his decision in the
2015 California lawsuit quoted at the beginning of
this chapter.
Suicide Prevention and Disability
In 2014, the State of Connecticut issued
the “Connecticut Strategic Plan for Suicide
Prevention (PLAN 2020)” to increase the
effectiveness of suicide prevention.
119
This was
the first known suicide prevention effort to
specifically address disability issues. Notably, it
singled out disability- specific suicide risk factors
including:
Difficulties navigating social and financial
services;
Stress of chronic stigma and discrimination;
The loss or threat of loss of independent
living, and
Institutionalization or hospitalization.
Further, Plan 2020 included acknowledgement
that:
The active disability community in
Connecticut has been vocal about the need
for suicide prevention services, including
disability cultural competency;
There may be unintended consequences of
assisted suicide legislation on people with
disabilities;
Many assume disability is a fate worse than
death; and
People with disabilities have a right to
responsive suicide prevention services.
Plan 2020 recommendations included:
Training practitioners to develop expertise
in working with people with disabilities who
are suicidal; and
Not assuming that suicide is a rational
response to disability.
Consequences for People with
Intellectual and Developmental
Disabilities
Assisted suicide laws also have consequences
for people with intellectual and developmental
disabilities (I/DD). There is a major emphasis
currently in I/DD services on future planning and
end- of- life care.
120
Families and professionals
who endorse assisted suicide may advocate
for people with I/DD to have this option with
guardian consent. This raises complex issues
beyond the scope of this study, such as surrogate
versus supportive decision making. There is also
a history of institutionalization, as was addressed
above for psychiatric survivors, which has been
shown, in many cases, to violate the Americans
with Disabilities Act (ADA) and the Supreme
Court Olmstead decision.
121
People of Color, Healthcare Disparity,
and Assisted Suicide Laws
There is concern about the impact of assisted
suicide laws on people of color, as has been
shown both through research
122
and statements
from legislators and other opinion leaders
The Danger of Assisted Suicide Laws 47
(seelater in this section). This is true despite data
from the Oregon Health Authority consistently
showing that mostly white, educated, insured
people request assisted suicide.
123
The Pew Research Center in 2013 found that
65 percent of people in the African American
and Hispanic communities oppose these laws.
124
Anita Cameron explained that “black, indigenous,
and [other] people of color” are at particular risk
of being harmed by assisted suicide laws.
125
In the run- up to passage of the California law,
opposition from Latino legislators nearly stopped
it. For example, Assemblyman Jimmy Gomez
said the bill had insufficient protections for
vulnerable patients. He said he grew up without
health insurance and
watched his father delay
getting treatment for
cancer until it was too
late. He worried that
uninsured patients would
be more likely to choose
assisted death because
they felt it was their only
treatment option, while those who do not speak
English might not fully understand the choice.
“How do we deal with the fact that the system
is fundamentally unfair to people in underserved
communities?” hesaid.
126
In Washington, DC, with half its population
being African American, there was significant
resistance to an assisted suicide bill. The
Washington Post quoted Patricia King, a
Georgetown Law School professor who has
written about the racial dynamics of assisted
death, when she said that “Many in the black
community distrust the health- care system
and fear that racism in life will translate into
discrimination in death.... Historically, African
“Historically, African Americans
have not had a lot of control over
their bodies, and I don’t think
offering them assisted suicide is
going to make them feel more
autonomous.”
Americans have not had a lot of control over
their bodies, and I don’t think offering them
assisted suicide is going to make them feel
more autonomous.” The Post continued, “Some
worry that blacks, who tend to have less access
to treatment and preventive care, may think
that ending their lives early is their best option
when given a terminal diagnosis.”
127
An opinion
piece in The Hill by Dr. Lydia S. Dugdale also
linked assisted suicide to the facts of healthcare
disparities affecting African American patients.
She wrote,
A study... found that black women are
more than twice as likely as white women
to die from cervical
cancer— a disease
which is largely
preventable....
Still other studies
found that blacks
are less likely than
non-Hispanic whites
to be referred for
cardiac procedures, to receive opiate pain
medication in the emergency room, or
to be referred for evaluation for kidney
transplantation once on dialysis....
Each day doctors strive to care for their
patients, regardless of race, ethnicity, or
socioeconomic status. Many are cognizant
of past abuses... and are keen to
demonstrate that things have changed. But
if physician- assisted suicide bills are passed,
particularly in places with predominantly
minority and vulnerable populations, we may
just be adding to the atrocities committed
by society and the health profession toward
black and Hispanic patients.
128
48 National Council on Disability
Improvements in Palliative Care
Palliative care is comfort care that affords
relief, as opposed to curative care. In the last
decade, the field of palliative care has developed
significantly.
One aspect of palliative care is palliative
sedation. In rare cases, when other forms of
palliative care cannot relieve significant pain or
discomfort, the patient can be sedated to the
point where the discomfort is relieved while the
dying process takes place, in a way that does not
cause or hasten death.
129
This and other aspects
of palliative care today can provide a legal solution
to significantly painful or uncomfortable deaths
that do not endanger
others in the way that
assisted suicide laws do.
Ideal approaches to
palliative care should
encompass social and
lifestyle interventions
as well as medical
supports. There has
been an increased
emphasis on cultural
competence as the context in which palliative
care should be understood and practiced.
Arguably, living with disability entails many
cultural and social factors that should be
addressed by professionals working with people
with functional limitations (and their families)
at the end of life. Improvements in palliative
care have the potential to reduce requests for
hastening one’s death.
The Criminalization of Pain
Disability activist Anita Cameron has written
about how “Our country is in the midst of an
[Palliative sedation] and other
aspects of palliative care today
can provide a legal solution
to significantly painful or
uncomfortable deaths that do not
endanger others in the way that
assisted suicide laws do.
opioid crisis which has resulted in what I call
the criminalization of pain.... Many people
who depend on opioids... to manage pain...
[findthemselves] subjected by doctors to drug
testing and pill counting... and feel as if they
are being treated like criminals.” Cameron points
out that emergency rooms treat such patients
like addicts and drug seekers. As more people
experience poor pain management, she argues,
it’s easy to see that if assisted suicide is legal, this
could drive increased requests for lethal drugs.
Cameron commented, “How ironic that it may
become easier... to get a prescription to die
than one to relieve pain.... Policymakers should
be working to increase
access to... palliative
care, not enacting laws
that allow doctors [to
hasten... deaths].”
130
Cameron’s concerns
are echoed by others’
findings. In fact, the
news media and the
Centers for Disease
Control have reported
a rise in suicidal thinking and actual suicides
among people with chronic pain who are denied
the drugs they need, especially among veterans,
people in rural areas with limited healthcare
choices, and people of color.
131
Also, writers in
the Journal of Palliative Medicine and the Journal
of the American Medical Association have written
about how patients often fear the prospect of
unrelieved pain. Unfortunately, more physicians
withhold pain medication because of ungrounded
concerns about patient addiction or that higher
doses may accelerate death through respiratory
suppression. Appropriate pain relief, however,
rarely does either.
132
The Danger of Assisted Suicide Laws 49
50 National Council on Disability
Chapter5: Recommendations
N
CD has considered recommending ways
to “improve” assisted suicide proposals
and laws by making their provisions
more stringent, but has decided against doing
so, because the Council does not believe that
added safeguards, modified safeguards, or indeed
safeguards of any kind, will remove the inherent
dangers in assisted suicide laws. Also, such a
message can be readily confused with the idea
that legalized assisted suicide is acceptable as
long as its rules are stronger, which is not true.
On the contrary, the basic dangers of legalizing
assisted suicide are inherent and cannot be
eradicated.
Implementation of assisted suicide laws has
demonstrated that even the current “safeguards,”
which are modest at best, are easily circumvented.
Rather than strengthening safeguards, the
tendency has been either to propose looser rules
or to simply disregard them, notwithstanding the
letter of the law. Examples from other countries
have also demonstrated that once assisted suicide
seems “safe,” then euthanasia and assisted suicide
for nonterminal diseases becomes a reasonable
next step. Thus, there is no reason to believe that
better laws, training of physicians, data collection or
safeguards will provide real protection from harms
and abuse in any meaningful way.
Congress
Congress should pass a resolution similar to H.Con.Res.80 from the 115th Congress to
express the Sense of the Congress that assisted suicide puts everyone, particularly people
with disabilities, at risk of deadly harm.
Congress should amend the Social Security Act to remove Medicaid’s statutory bias for
institutional long- term care rather than long- term services and supports (LTSS) provided for
people living in the community. Although the Olmstead decision calling for Medicaid home
and community- based services rather than institutionalization for people with disabilities has
reduced states’ emphasis on institutionalization, the funding bias remains.
Congress should explore legislative options to provide home and community- based LTSS
through the Medicare program. Options could include expanding the limited in- home benefit;
building on supplemental services recently made available through Medicare Advantage; and
(continued)
The Danger of Assisted Suicide Laws 51
Congress, continued
creating a new complex care benefit that would deliver a comprehensive range of healthcare
services, including LTSS.
Congress should consider creating a new, public, long- term care insurance program to
pay for a broad range of long- term supports and services, such as personal care aides, home
modifications, or assisted living costs. Consideration should be given to supporting the program
through a modest tax, comparable to recently enacted legislation in Washington State.
Congress should consider legislation for a comprehensive LTSS benefit that is not means tested.
Executive Branch
The US Department of Health andHuman Services (HHS)
The Substance Abuse and Mental Health Services Administration (SAMHSA)
SAMHSA should address the mental health challenges of living with a disability and chronic
conditions, including challenges to people with a terminal prognosis, in suicide prevention
efforts and education.
The National Institute on Disability, Independent Living, and Rehabilitation
Research (NIDILRR)
NIDILRR should conduct research on disability- related risk factors in suicide prevention, as
well as research on people with disabilities who request assisted suicide and euthanasia.
HHS Office for Civil Rights (OCR)
OCR should issue a regulation specifically requiring nondiscrimination in suicide prevention
services which states that physicians must treat a request for assisted suicide or any other
form of hastened death the same, regardless of whether or not the patient has a disability;
an individual’s expression of wanting to die should not be explored any less rigorously or fully
solely because the individual has a disability, or a chronic or terminal condition.
As part of this nondiscrimination requirement, OCR should make clear that all HHS suicide
prevention grants and services must comply with existing disability rights laws, including
the ADA, Sections504 and 508 of the Rehabilitation Act, and Section1557, including the
provisions requiring accessible communications, so that all videos, documents, and other
products ensure access to persons with disabilities.
(continued)
52 National Council on Disability
Executive Branch, continued
OCR should issue a clarifying regulation pursuant to Section504 and Section1557 and
any other relevant federal laws to require physicians to provide people with disabilities with
information on the full array of available clinical treatments and available LTSS and requiring
that referrals to such treatments and services be given if requested. The regulation should
require hospitals to create a disability ombudsperson position who is authorized to facilitate
communication between healthcare providers and patients with disabilities or their proxies
and advocate on the patient’s behalf, when required, to ensure that all clinical and LTSS
options and choices are made available.
State Legislatures, and State Referenda and Initiatives
States should not legalize any form of assisted suicide or active euthanasia, whether called
by these terms or any other terms. States must, rather, ensure a strong healthcare system
that includes LTSS for all, including people with disabilities with or without a terminal
prognosis; ensure that people with disabilities are protected from discrimination; and provide
services that enable independent living and supported self- determination for people with
disabilities.
The Danger of Assisted Suicide Laws 53
State Agencies That Deal withSuicide Prevention
All state agencies that deal with suicide prevention should address the specific challenges of
people with disabilities and people with chronic conditions, including people with a terminal
prognosis.
State agencies that deal with suicide prevention should appropriate funding for research
to address the challenges of people with disabilities and people with chronic conditions,
including people with a terminal prognosis, on disability- related risk factors in suicide
prevention, as well as research on gathering data directly from people who request assisted
suicide and euthanasia.
Professional Healthcare Practitioners
Professional healthcare practitioners should always inform patients with disabilities,
including those with a terminal prognosis and regardless of the cause of their disability,
about the full array of clinical treatment options available to them. Patients should also
always be informed about and referred to available LTSS, including palliative care, personal
care and assistance, counseling, skilled nursing, and other supports available through
government programs, health insurance, and community- based sources.
Primary Care Practitioners, Specialty Providers, Clinics, Hospitals,
Laboratories, Diagnostic and Therapy Centers, and
Other Healthcare Services
Primary care practitioners, specialty providers, clinics, hospitals, laboratories, diagnostic
and therapy centers, and other healthcare services must offer a full range of physical,
communication, and programmatic access accommodations for patients with disabilities
that are in compliance with the ADA and Section504 of the Rehabilitation Act, and that
are consistent with culturally competent care. Similarly, LTSS programs, particularly those
provided in a community location, must also ensure physical accessibility and provide any
accommodations clients require to participate fully as required by the ADA and Section504.
Medical Schools and Other Healthcare Professional Education
and Training Programs
Medical school and other healthcare professional education and training programs,
including hospice, should require courses on skills and competencies needed to provide
quality interprofessional health care to patients with disabilities and should develop a core
set of disability competencies based on the Ohio State cultural competency standards
133
54 National Council on Disability
(continued)
Medical Schools and Other Healthcare Professional Education
and Training Programs, continued
The Danger of Assisted Suicide Laws 55
to facilitate the integration of disability content into healthcare education and training
programs, specifically:
Training on palliative and other end- of- life care, including palliative sedation in the rare
cases when patients are dying in unrelievable pain or other significant discomfort.
Core competencies should also include:
Contextual and conceptual frameworks on disability,
Professionalism and patient- centered care,
Legal obligations and responsibilities for caring for patients with disabilities,
Teams and systems- based practice,
Clinical assessment, and
Clinical care over the life span and during transitions.
56 National Council on Disability
Endnotes
1 National Council on Disability (NCD), “Assisted Suicide: A Disability Perspective Position Paper,” March 24,
1997, https://www.ncd.gov/publications/1997/03241997.
2 NCD, “Cover Memorandum upon the Reissuance of the NCD Statement Opposing Legalization of Assisted
Suicide,” June 9, 2005, https://www.ncd.gov/publications/2005/cover-memorandum-upon-reissuance-ncd-
statement-opposing-legalization-assisted-suicide.
3 Washington v. Glucksberg, 521 US 702 (1997) and Vacco v. Quill, 521 US 793 (1997).
4 Some of these laws became effective in a later year. For example, the Hawaii statute did not become effective
until 2019. Our Care, Our Choice Act, 2018 Haw. Sess. Laws Act 2739, § 12 at 39. https://www.capitol.hawaii
.gov/session2018/bills/GM1102_.PDF.
5 At the federal level, Section1553 of the Affordable Care Act prohibits discrimination against individuals or
institutional healthcare entities that do not provide assisted suicide services.
6 Carol Gill, Ph.D., and member, Advisory Panel, NCD Bioethics series, personal communication to the author,
April 6, 2019, and Carol J. Gill, Ph.D., “Disability, Constructed Vulnerability, and Socially Conscious Palliative
Care,” Journal of Palliative Care 22, no. 3 (2006): 186–89.
7 S. I. Rosenbaum, “Killing with Kindness: Why the Death with Dignity Act Endangers People with Disabilities,”
The Boston Phoenix, October 31, 2012, https://dredf.org/wp-content/uploads/2012/08/Boston-Phoenix-on-
Question.pdf.
8 Paul Longmore, “The Resistance: The Disability Rights Movement and Assisted Suicide,” in Why I Burned My
Book and Other Essays on Disability (Philadelphia: Temple University Press, 2003): 178–95.
9 Laurie Wilcox, “My Sister and I Are Nurses Who Are Disabled by Life-Shortening Diseases. Let Us Die Our
Own Way,” New Jersey Star Ledger Opinion, November 13, 2018, https://www.nj.com/opinion/2018/11/
my_sister_and_i_are_nurses_who_are_disabled_by_lif.html. This is a summary. For example, regarding the
California law, the California Medical Association listed its rules in detail. See https://www.cmadocs.org/store/
info/productcd/3459/t/the-california-end-of-life-option-act.
10 Dr. Herbert Hendin and Dr. Kathleen Foley, “Physician-Assisted Suicide in Oregon: A Medical Perspective,”
Michigan Law Review, 106 (June 2008): 1613, accessed May 23, 2018, https://dredf.org/wp-content/
uploads/2012/08/Hendin-Foley-Michigan-Law-Review.pdf. Herbert Hendin was the Chief Executive Officer
and Medical Director, Suicide Prevention International, and Professor of Psychiatry, New York Medical
College. Kathleen Foley was an attending neurologist, Memorial Sloan-Kettering Cancer Center; Professor of
Neurology, Neuroscience, and Clinical Pharmacology, Weill Medical College of Cornell University; and Medical
Director, International Palliative Care Initiative of the Open Society Institute.
11 Some of the ways supposed protections are sidestepped apply specifically to people with disabilities. Others
might apply to some people without disabilities as well, particularly elders and people who are underinsured.
But even these tend to have a disproportionate impact on people with disabilities, due to many factors:
historic discrimination in the medical field toward people with disabilities; the lack of treatments and other
options; and the vulnerability of some disabled people to coercion, or to feeling burdensome or unwanted by
trusted individuals including professionals, family members, and caregivers.
12 NCD, “Assisted Suicide.” In this 1997 position paper, NCD stated: “The pressures upon people with
disabilities to choose to end their lives, and the insidious appropriation by others of the right to make that
choice for them are already way too common in our society. These pressures are increasing and will continue
to grow as managed health care and limitations upon health care resources precipitate increased ‘rationing’ of
health care services and health care financing.” This was attributed in part to: “One author has observed that,
The Danger of Assisted Suicide Laws 57
as health care costs increase, while funding for health care and supportive programs is restricted, ‘assisted
suicide becomes a more cost- effective, expedient, and ultimately socially acceptable option.’” Paul Steven
Miller, “The Impact of Assisted Suicide on Persons with Disabilities—Is It A Right Without Freedom?” Issues
in Law & Medicine 9 (1993): 54, 56 n. 33.
13 Kenneth R. Stevens Jr., MD, “Oregon Rationing Cancer Treatment But Offering Assisted Suicide to Cancer
Patients—Paying to Die But Not to Live,” Physicians for Compassionate Care Educational Foundation, June
6, 2008, http://www.pccef.org/articles/art67.htm. Stevens is Professor Emeritus and former Chairman of
Radiation Oncology at Oregon Health & Science University.
14 Stevens, “Oregon Rationing Cancer Treatment.”
15 Dan Springer, “Oregon Offers Terminal Patients Doctor-Assisted Suicide Instead of Medical Care,” Fox News,
July 28, 2009, https://www.foxnews.com/story/oregon-offers-terminal-patients-doctor-assisted-suicide-
instead-of-medical-care.
16 H. Rex Greene, MD, personal communication to the author, July 5, 2009.
17 Cal. Health & Safety Code § 443.13(c).
18 The Center for Bioethics and Culture Network, Compassion and Choice Denied, October 3, 2016, https://
youtu.be/hwLs3D062Vk. Video about Stephanie Packer. See also, Bradford Richardson, “Assisted-Suicide
Law Prompts Insurance Company to Deny Coverage to Terminally Ill California Woman,” Washington Times,
October 20, 2016, https://www.washingtontimes.com/news/2016/oct/20/assisted-suicide-law-prompts-
insurance-company-den/.
19 Patients Rights Action Fund, Physician Assisted Suicide—The Real Effects, May 31, 2017, https://www
.youtube.com/watch?v=CWrpr_5e4RY. Video about Dr. Brian Callister’s patients. See also Australian Care
Alliance, An international analysis of “Fifteen Fatally Flawed Experiments: California,” accessed January 27,
2019, https://www.australiancarealliance.org.au/california.
20 Nina Shapiro, “Terminal Uncertainty,” Seattle Weekly, January 14, 2009, https://dredf.org/wp-content/
uploads/2012/08/Terminal-Uncertainty.pdf. This article’s subtitle is, “Washington’s new Death with Dignity law
allows doctors to help people commit suicide once they’ve determined that the patient has only six months
to live. But what if they’re wrong?” The author explores both the clinical and statistical uncertainty in terminal
prognoses.
21 Jeanette Hall, letter to the editor, Boston Globe, October 4, 2011, http://archive.boston.com/bostonglobe/
editorial_opinion/letters/articles/2011/10/04/she_pushed_for_legal_right_to_die_and___thankfully___was_
rebuffed/.
22 Dr. Ken Stevens, Jeanette Hall’s oncologist, interview with the author, January 18, 2019.
23 Anita Cameron, “Testimony Opposing New York Assisted Suicide Bill A2383A,” Not Dead Yet, May 3, 2018,
http://notdeadyet.org/testimony-of-anita-cameron-opposing-new-york-assisted-suicide-bill-a2383a.
24 Nashelly Chavez, “Woman in Wheelchair Drowns in Bizarre Accident on Sacramento River,” Sacramento Bee,
July 5, 2016, https://www.sacbee.com/news/local/crime/article87867037.html, and Catherine Campisi, Retired
Director, California Department of Rehabilitation, personal communication to the author, April 21, 2019.
25 Harris, Louis & Associates, The ICD Survey of Disabled Americans: Bringing Disabled Americans into the
Mainstream (1986): 55; K. A. Gerhart, etal., “Quality of Life Following Spinal Cord Injury: Knowledge and
Attitudes of Emergency Care Providers,” Annals of Emergency Medicine 23 (1994): 807–12; P. Cameron
etal., “The Life Satisfaction of Nonnormal Persons,” Journal of Consulting and Clinical Psychology 41 (1973):
207–14; C. Ray and J. West, “Social, Sexual and Personal Implications of Paraplegia,” Paraplegia 22 (1984):
75–86; R. Stensman, “Severely Mobility-Disabled People Assess the Quality of Their Lives,” Scandinavian
Journal of Rehabilitation Medicine 17 (1985): 87–99; G. G. Whiteneck etal., “Rocky Mountain Spinal Cord
Injury System Report,” National Institute of Handicapped Research (1985): 29–33; and M. G. Eisenberg and
C. C. Saltz, “Quality of Life Among Aging Spinal Cord Injured Persons: Long Term Rehabilitation Outcomes,”
Paraplegia 29 (1991).
58 National Council on Disability
26 Richard Radtke, “A Case Against Physician-Assisted Suicide,” Journal of Disability Policy Studies 16, no. 1
(Summer 2005): 58–61. This description was updated to include Radtke’s death in 2012.
27 E. B. Lamont etal., “Some Elements of Prognosis in Terminal Cancer,” Oncology (Huntington) 9 (1999):
1165–70; M. Maltoni etal., “Clinical Prediction of Survival Is More Accurate Than the Karnofsky Performance
Status in Estimating Lifespan of Terminally-Ill Cancer Patients,” European Journal of Cancer 30A, no. 6 (1994):
764–66; N. A. Christakis and T. J. Iwashyna, “Attitude and Self-Reported Practice Regarding Prognostication
in a National Sample of Internists,” Archives of Internal Medicine 158, no. 21 (1998): 2389–95; J. Lynn etal.,
“Prognoses of Seriously Ill Hospitalized Patients on the Days Before Death: Implications for Patient Care and
Public Policy,” New Horizons 5, no. 1 (1997): 56–61. Note that “Seventeen percent of patients [outlived their
prognosis] in the Christakis study. This roughly coincides with data collected by the National Hospice and
Palliative Care Organization, which in 2007 showed that 13 percent of hospice patients around the country
outlived their 6- month prognoses.... When a group of researchers looked specifically at patients with three
chronic conditions— pulmonary disease, heart failure, and severe liver disease— they found that many more
people outlived their prognosis than in the Christakis study. Fully 70 percent of the 900 patients eligible for
hospice care lived longer than 6 months, according to a 1999 paper published in the Journal of the American
Medical Association.” See Nina Shapiro, “Terminal Uncertainty.”
28 Lisa Esposito, “What’s Really Involved in Physician-Assisted Death?” US News Health, November 3, 2017,
https://health.usnews.com/health-care/patient-advice/articles/2017-11-03/whats-really-involved-in-physician-
assisted-death. For example, “The patient cannot be suffering from impaired judgment due to depression or
another psychiatric or psychological condition.”
29 N. Gregory Hamilton, MD, and Catherine Hamilton, MA, “Competing Paradigms of Responding to Assisted
Suicide Requests in Oregon: Case Report,” presented at the American Psychiatric Association Annual
Meeting, New York, New York, May 6, 2004, http://www.pccef.org/articles/art28.htm and N. Gregory
Hamilton, MD, “Testimony to the Select Committee on the Assisted Dying for the Terminally Ill Bill,” House of
Lords, Portland, Oregon, December 10, 2004, http://www.pccef.org/articles/art32HouseOfLords.htm.
30 Herbert Hendin, “Suicide, Assisted Suicide and Euthanasia: Lessons from the Dutch Experience,” testimony
presented to the Subcommittee on the Constitution, US House of Representatives Oversight Hearing,
Washington, DC, April 29, 1996.
31 For example, the Oregon Death with Dignity Act (DWDA), Or. Rev. Stat. 127.825s.3.03., https://www.oregon
.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/
ors.aspx. This section states “If, in the opinion of the attending physician or the consulting physician a patient
may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment,
either physician shall refer the patient for counseling. No medication to end a patient’s life in a humane and
dignified manner 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.” Thus, a
reference to “counseling” to determine the presence of a psychiatric or psychological disorder or depression
is only required if, in the opinion of the attending [or consulting] physician, a patient may be experiencing such
a condition. As is explained a few paragraphs later, very few such referrals are actually ever made, despite
evidence that people with depression are, in fact, receiving lethal drugs under the Oregon assisted suicide law.
32 For example, under the California law, see The California End of Life Option Act, Document # 3459, California
Medical Association (CMA) Legal Counsel, January 2016, accessed February 12, 2019, https://www.cmadocs
.org/store/info/productcd/3459/t/the-california-end-of-life-option-act.
33 NCD, “Assisted Suicide,” citing “e.g., Brief for Amici Curiae, Gay Men’s Health Crisis etal. in Vacco v. Quill,
No. 95-1858, and State of Washington v. Glucksberg, No. 96-110, October Term, 1996, at p. 15.”
34 NCD, “Assisted Suicide,” citing “the Council’s proposals as to how America might better afford people with
disabilities opportunities for independence, dignity, self- sufficiency, and full participation, [are available at]
National Council on Disability, Achieving Independence: The Challenge for the 21st Century (1996).”
The Danger of Assisted Suicide Laws 59
35 H. Rex Greene, “Opposition to Neutrality on AB 651H,” letter to the California Medical Association (CMA)
Council on Ethical Affairs, February 22, 2006, https://dredf.org/public-policy/assisted-suicide/opposition-to-
neutrality-on-ab-651/.
36 Oregon Death with Dignity Act, 2017 Data Summary, accessed February 18, 2019, https://www.oregon.gov/
oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/
year20.pdf.
37 Oregon Death with Dignity Act, 2018 Data Summary, accessed March 16, 2019, https://www.oregon.gov/
oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/
year21.pdf.
38 Regarding Colorado, “Although the law requires a referral to a psychiatrist or psychologist ‘if the attending
physician believes that the individual may not be mentally capable of making an informed decision,’ only 1 out
of 69 people (1.4%) is reported as having been so referred.” Australian Care Alliance, accessed February 17,
2019, https://www.australiancarealliance.org.au/colorado.
39 L. Ganzini etal., “Attitudes of Oregon Psychiatrists Towards Assisted Suicide,” American Journal of Psychiatry
153 (1996): 1469–75.
40 John Cloud, “Study: Doctors Don’t Always Spot Depression,” Time Magazine, July 30, 2009, http://content
.time.com/time/health/article/0,8599,1913312,00.htm.
41 For example, for Washington State and Oregon: Revised Code of Washington 70.245.010; Oregon Legislative
Statue 127.800 §1.01.
42 Hendin and Foley, “Physician Assisted Suicide.”
43 William Toffler, “A Doctor-Assisted Disaster for Medicine,” Wall Street Journal Online, August 17, 2015, https://
www.wsj.com/articles/a- doctor- assisted- disaster- for- medicine-1439853118.
44 Linda Ganzini, Elizabeth R. Goy, and Steven K. Dobscha, “Prevalence of Depression and Anxiety in Patients
Requesting Physicians’ Aid in Dying: Cross Sectional Survey,” British Medical Journal 337 (2008): 1–5,
accessed February 18, 2019, https://www.bmj.com/content/337/bmj.a1682.
45 David W. Kissane, “The Contribution of Demoralization to End of Life Decisionmaking,” Hastings Center
Report 34, no. 4 (2004): 21–31; and Sophie Robinson etal., “A Systematic Review of the Demoralization
Syndrome in Individuals with Progressive Disease and Cancer: A Decade of Research,” Journal of Pain and
Symptom Management (March 3, 2015): 605–8.
46 Even if someone is depressed and/or suicidal, there are alternatives to hospitalization. There is an increasing
recognition that simply hospitalizing an individual is not an effective way to address suicide. See Susan
Stefan, JD, “Transforming Suicide Assessment, Prevention and Treatment Approaches: The New Consensus,”
National Association of Rights Protection and Advocacy, accessed February 18, 2019, http://narpa.org/
conferences/2017/transforming- suicide- assessment- prevention- and- tx- approaches. Also see American
Psychiatric Association, “Hospitalization, by itself, is not a treatment” (2003), and American Association of
Suicidology/Suicide Prevention Resource Center, “Sadly, there is no evidence whatsoever that psychiatric
hospitalization prevents suicide” (2010) and Joint Commission, “Hospitalization is often necessary for a
patient’s immediate safety, but hospitalization used solely as a containment strategy may be ineffective
or counterproductive and considered by the patient as a disincentive or penalty for expressing suicidal
thoughts”(2016).
47 Carol Gill, Ph.D. (Professor Emerita in the Department of Disability and Human Development at the University
of Illinois at Chicago [UIC]), “Depression in the Context of Disability and the ‘Right to Die,’” Theoretical
Medicine 25 (2004): 171–98. Also, “Health Professionals, Disability, and Assisted Suicide: An Examination of
Relevant Empirical Evidence and Reply to Batavia (2000),” Psychology, Public Policy, and Law 6, no. 2 (2000):
526–45. Also, Carol J. Gill, Ph.D., “No, We Don’t Think Our Doctors Are Out to Get Us: Responding to the
Straw Man Distortions of Disability Rights Arguments Against Assisted Suicide,” Disability and Health Journal
3 (2010): 31–38. Also, “Disability, Constructed Vulnerability, and Socially Conscious Palliative Care,” Journal of
Palliative Care 22, no. 3 (2006): 183–89.
60 National Council on Disability
48 Carol Gill, Ph.D., personal communication to the author, April 6, 2019, and Carol J. Gill, Ph.D., “Disability,
Constructed Vulnerability, and Socially Conscious Palliative Care.”
49 Susan D. Block and J. Andrew Billings, “Patient Requests to Hasten Death: Evaluation and Management in
Terminal Care,” Archive of Internal Medicine 154, no.18 (1994): 2039–47.
50 Erin Barnett, “A Family Struggle: Is Mom Capable of Choosing to Die?,” The Oregonian, Oct. 17, 1999.
51 Patients Rights Council, “Facts about Hemlock* and Caring Friends,” http://www.patientsrightscouncil
.org/site/hemlock- and- caring- friends/. “In mid 2003, the Hemlock Society changed its name to ‘End- of-Life
Choices.’ At the end of 2004, End- of-Life Choices merged with Compassion in Dying. The organization is now
known as ‘Compassion and Choices.’”
52 Peter Goodwin, “Charting a New Course, Building on a Solid Foundation, Imagining a Brighter Future for
America’s Terminally Ill,” transcript of presentation at 13th National Hemlock Society Biennial Conference,
January 11, 2003, San Diego, California. Also, Compassion in Dying of Oregon, Summary of Hastened
Deaths, data attached to Compassion in Dying of Oregon’s IRS Form 990 for 2003. Also, Dr. Elizabeth Goy
of Oregon Health and Science University was an Assistant Professor in the Department of Psychiatry,
School of Medicine. In 2004, members of the British House of Lords traveled to Oregon seeking information
regarding Oregon’s assisted suicide law for use in their deliberations about a similar proposal that was under
consideration in Parliament. They held closed- door hearings in which Goy spoke on December 9 and 10, 2004
and published the proceedings on April 4, 2005. House of Lords Select Committee on the Assisted Dying for
the Terminally Ill Bill, Assisted Dying for the Terminally Ill Bill [HL] Vol. II: Evidence (London: The Stationery
Office Limited, 2005), 291, Question 768, available at: http://www.publications.parliament.uk/pa/ld200405/
ldselect/ldasdy/86/86ii.pdf (accessed January 29, 2019). And Kenneth R. Stevens, Jr., MD, The Proportion
of Oregon Assisted Suicides by Compassion & Choices Organization, Physicians for Compassionate Care
Educational Foundation, March 4, 2009, http://www.pccef.org/DOWNLOADS/AssistedSuicidesbyCC2009
report.pdf.
53 This is documented extensively in Chapter3.
54 William Yardley, “First Death for Washington Assisted-Suicide Law”, New York Times, May 23, 2009,
http://www.nytimes.com/2009/05/23/us/23suicide.html?_r=0.
55 Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease.
56 “Sawyer Arraigned on State Fraud Charges,” KTVZ.com, Sept. 7, 2011, https://www.ktvz.com/news/crime/
sawyers- go- to- prison- victims- see- justice- but- money/68441556.
57 Oregon Death with Dignity Act, 2018 Data Summary.
58 Carol Gill, Ph.D., personal communication to the author, April 6, 2019, and Carol J. Gill, Ph.D., “Disability,
Constructed Vulnerability, and Socially Conscious Palliative Care.”
59 Oregon Death with Dignity Act (DWDA), Or. Rev. Stat. 127.800 et seq., https://www.oregon.gov/oha/PH/
PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ors.aspx.
60 NCD, “Cover Memorandum.”
61 S. H. Miles, “Physicians and Their Patients’ Suicides,” JAMA 271 (1994): 1786–88.
62 NCD, “Assisted Suicide: A Disability Perspective.”
63 Carol Gill, Ph.D., personal communication to the author, April 6, 2019, and Carol J. Gill, Ph.D., “Disability,
Constructed Vulnerability, and Socially Conscious Palliative Care.”
64 John R. Bach, “Ventilator Use by Muscular Dystrophy Association Patients,” Archives of Physical Medicine
Rehabilitation 73, no. 2 (February 1992),
https://www.archives- pmr.org/article/0003-9993(92)90098-H/fulltext.
65 Carol Gill, Ph.D., personal communication to the author, April 6, 2019, and Carol J. Gill, Ph.D., “Disability,
Constructed Vulnerability, and Socially Conscious Palliative Care.”
66 Hendin and Foley, “Physician-Assisted Suicide in Oregon,” 1627–28.
67 “Oregon State Assisted Suicide Reports Substantiate Critics’ Concerns,” Not Dead Yet, October 4, 2016,
http://notdeadyet.org/2016/10/oregon- state- assisted- suicide- reports- substantiate- critics- concerns.html,
accessed February 1, 2019.
The Danger of Assisted Suicide Laws 61
68 Oregon Department of Human Services, “No Authority to Investigate Death with Dignity Case,” News
Release, March 4, 2005,
https://dredf.org/wp- content/uploads/2012/08/Oregon-DHS.pdf.
69 For example, see Oregon Health Authority, “Methods,” Death with Dignity Annual Reports, available
at https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/
DEATHWITHDIGNITYACT/Documents/methods.pdf (accessed July 24, 2019).
70 State of Connecticut, Division of Criminal Justice, “Testimony of the Division of Criminal Justice,” Hearing on
H.B. No. 7015, Joint Committee on Judiciary, March 18, 2015. Also State of Connecticut, Division of Criminal
Justice, “Testimony of the Division of Criminal Justice,” Hearing on H.B. No. 5898, Joint Committee on Public
Health, March 18, 2019, https://www.cga.ct.gov/2019/PHdata/Tmy/2019HB-05898-R000318-CT Division of
Criminal Justice-TMY.PDF. The Division of Criminal Justice used the same language regarding the same
section number in both instances.
71 Daniel Callahan, “Organized Obfuscation: Advocacy for Physician-Assisted Suicide,” Hastings Center Reports
(September–October 2008): 32.
72 Assisted suicide bills and laws generally state explicitly that payments of any life, health, or accident
insurance, or annuity policy, are unaffected if death is by assisted suicide.
73 Maryland state Senator Bob Cassilly, “Sen. Cassilly: Medically Assisted Suicide Sends Message to Elderly
That They Are a Burden,” Baltimore Sun, February 26, 2019, https://www.baltimoresun.com/news/opinion/
readersrespond/bs- ed- rr- physician- assisted- suicide- elderly- burden- letter-20190226- story.html.
74 Former Hawaii Governors George Ariyoshi, John Waihee, Benjamin Cayetano, and Neil Abercrobie, “Allowing
Life- ending Medication Is a Compassionate Choice”, Honolulu Star Advertiser, December 15, 2016, https://
www.staradvertiser.com/2016/12/15/editorial/island- voices/allowing- life- ending- medication- is- a- compassionate-
choice/, reprinted by Compassion & Choices, accessed March 2, 2019, https://compassionandchoices.org/
news/allowing- life- ending- medication- compassionate- choice/.
75 “Some Oregon and Washington State Assisted Suicide Abuses and Complications,” compiled by the
Disability Rights Education & Defense Fund (DREDF), accessed March 2, 2019.
https://dredf.org/public-
policy/assisted- suicide/some- oregon- assisted- suicide- abuses- and- complications/. Also see Stephanie Packer,
Youtube video at https://youtu.be/hwLs3D062Vk, October 3, 2016, and Dr. Brian Callister, Youtube video at
https://www.youtube.com/watch?v=CWrpr_5e4RY, May 31, 2017.
76 American Medical News, “Oregon Nixes Use of Term “Physician- assisted Suicide—Right- to- die Advocates
Hope that Changing the Language May Help Pass Laws in Other States,” November 6, 2006, https://
amednews.com/article/20061106/profession/311069952/7/.
77 Not Dead Yet, “Oregon State Assisted Suicide Reports Substantiate Critics’ Concerns”, May 16, 2018, http://
notdeadyet.org/oregon- state- assisted- suicide- reports- substantiate- critics- concerns. “The Oregon Health
Division assisted suicide reports show that non- terminal people receive lethal prescriptions every year
except the first.... The prescribing physicians’ reports to the state include the time between the request for
assisted suicide and death for each person. However, the online state reports do not reveal how many people
outlived the 180- day prediction. Instead, the reports give that year’s median and range of the number of days
between the request for a lethal prescription and death.... In 2017, at least one person lived 603 days; across
all years, the longest reported duration between the request for assisted suicide and death was 1009 days.
In every year except the first year, the reported upper range is significantly longer than 180 days (six months).
[Yet] the definition of ‘terminal’ in the statute... requires that the doctor predict that the person will die
within six months.” It cannot be known whether those who took the lethal drugs within the 180 days would
have lived longer had they waited longer.
78 Death with Dignity Data, Washington State Department of Health, https://www.doh.wa.gov/YouandYourFamily/
IllnessandDisease/DeathwithDignityAct/DeathwithDignityData. For example, Washington reports whether the
time from request to death was greater or less than 25 weeks. In the last 3 years, the percent who lived longer
than 25 weeks was 16, 12 and 10 percent of those who died. As in Oregon, it cannot be known whether those
who took the lethal drugs within the 180 days would have lived longer had they waited longer.
62 National Council on Disability
79 Oregon Death with Dignity Act, 2018 Data Summary.
80 Carol Gill, Ph.D., personal communication to the author, November 2, 2018.
81 Oregon Death with Dignity Act, 2018 Data Summary.
82 Although self- administration is touted as one of the key “safeguards” in US assisted suicide laws, whether
patient self- administration is legally required is a complicated question. For example, the terms “self-
administration,” “ingesting,” and/or “take” [the drugs] are sometimes absent, undefined, or are defined
differently than assisted suicide proponents’ descriptions suggest. By some analyses, the Oregon law is
ambiguous as to whether lethal drugs may only be administered by the patient him- or herself. The California
law clearly states that “’Self- administer’ means a qualified individual’s affirmative, conscious, and physical
act of administering and ingesting the aid-in- dying drug to bring about his or her own death,” although it also
states that “a person who is present may, without civil or criminal liability, assist the qualified individual by
preparing the aid-in- dying drug so long as the person does not assist the qualified person in ingesting the
aid-in- dying drug.” How much assistance is legal? If the qualified individual uses a feeding tube, may others
place the lethal agents in it? There are additional issues beyond the scope of this paper to fully explore.
Cal.Health & Safety Code § 443.13(p) & 443.14(a).
83 Patients Rights Council, “Washington State Issues 8th Official Report on Doctor-Prescribed Suicide,” accessed
May 23, 2018, http://www.patientsrightscouncil.org/site/washington/.
84 Rita Marker, Executive Director, Patients Rights Council, Commentary on California End of Life Option Act,
ABX2-15, 2015. Marker has been the Executive Director of the Patients Rights Council since it began in l987.
Marker, a practicing attorney, is also the author of the critically acclaimed book, Deadly Compassion (Morrow,
1993; Harper/Collins, 1994; Avon Books, 1995).
85 Our Care, Our Choice Act, H.B. 2739, H.D. 1, 29th Leg. Sess., Reg Sess. (2018), Section3, §14 (c), pp. 18–19,
available at https://www.capitol.hawaii.gov/session2018/bills/GM1102_.PDF.
86 A complete listing of national disability organizations opposed to the legalization of assisted suicide can
be found at
http://notdeadyet.org/disability- groups- opposed- to- assisted- suicide- laws or https://dredf.org/
public- policy/assisted- suicide/national- disability- organizations- that- oppose- the- legalization- of- assisted- suicide/
(both accessed March 1, 2019). Many leading national medical associations, including the American Medical
Association (AMA) and the American College of Physicians (ACP), are also opposed to the legalization of
assisted suicide. See American Medical Association, Chapter5, “Opinions on Caring for Patients at the
End of Life, 5.8 Euthanasia,” accessed March 5, 2019,
https://www.ama- assn.org/sites/default/files/media-
browser/code- of- medical- ethics- chapter-5.pdf, and Annals of Internal Medicine, “Ethics and the Legalization
of Physician-Assisted Suicide: An American College of Physicians Position Paper,” accessed March 5, 2019,
http://annals.org/aim/article/2654458/ethics- legalization- physician- assisted- suicide- american- college- physicians-
position- paper.
87 Patients Rights Council, “Attempts to Legalize Euthanasia/Assisted-Suicide in the United States,” accessed
March 5, 2019,
http://www.patientsrightscouncil.org/site/failed- attempts- usa/.
88 Patients Rights Council, “Attempts to Legalize.”
89 ODonnell v. Harris, No. 37-2015-00016404 (Sup. Ct. S.D. County, July 24, 2015).
90 H.R. Con. Res. 80, 115th Cong., 1st Sess. (2017), https://www.congress.gov/bill/115th- congress/house-
concurrent- resolution/80/text.
91 The National Domestic Violence Hotline, “Domestic Violence & People with Disabilities,” https://www
.thehotline.org/is- this- abuse/domestic- violence- disabilities/, accessed February 13, 2019. Also Disability
Justice, “Abuse and Exploitation of People with Developmental Disabilities,”
https://disabilityjustice.org/justice-
denied/abuse- and- exploitation/, accessed February 13, 2019. Also Nora Baladerian, Ph.D., Thomas F. Coleman,
and Jim Stream, “Abuse of People with Disabilities,” A Report on the 2012 National Survey on Abuse of
People with Disabilities, Spectrum Institute, Disability and Abuse Project, 2013.
92 American Association of Retired Persons (AARP), “Fighting Against Elder Abuse and Exploitation,” March 4,
2015,
https://www.aarp.org/politics- society/advocacy/caregiving- advocacy/info-2015/fight- against- elder- abuse.
The Danger of Assisted Suicide Laws 63
html. Also Peck Law Group, “Elder Abuse Data and Statistics,” January 26, 2013, http://www.premierlegal
.org/elder- abuse- data- and- statistics/. Also National Center on Elder Abuse, https://ncea.acl.gov/whatwedo/
research/index.html, accessed February 9, 2019. Also National Adult Protective Services Association, http://
www.napsa- now.org/get- informed/what- is- abuse/, accessed February 9, 2019. Also New England Journal of
Medicine, “Elder Abuse,” November 12, 2015, https://www.nejm.org/doi/full/10.1056/NEJMra1404688.
93 Margaret Dore, “‘Death with Dignity’: What Do We Advise Our Clients?” King County Bar Association
(Bulletin), May, 2009, https://www.kcba.org/newsevents/barbulletin/BView.aspx?Month=05&Year=2009&AID=
article5.htm.
94 Patients Rights Council, “New Mexico ‘Elizabeth Whitefield End of Life Options Act’ (HB 90) 2019,”
http://www.patientsrightscouncil.org/site/new- mexico- elizabeth- whitefield- end- of- life- options- act- hb-90-2019-
analysis/.
95 John Kelly, interview with the author, January 30, 2019.
96 Oregon Health Authority, Public Health Division, Oregon Death with Dignity Act, 2017 Data Summary, 9
including n. 2, https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/
DEATHWITHDIGNITYACT/Documents/year20.pdf.
97 Bruce Darling, “Opposing Policy Option 2.”
98 Hawaii 2017 HB 201.
99 See, H.B. 2232, 80th Leg., Reg. Sess. §3 (as introduced) (Or. 2019).
100 H.B. 90, 54th Leg., 1st Sess. § 2(D) (N.M. 2019)(definition of “health care provider”), available at https://www
.nmlegis.gov/Sessions/19%20Regular/bills/house/HB0090.pdf.
101 H.B. 90, 54th Leg., 1st Sess. § 2(G) (N.M. 2019), definition of “prescribing health care provider”, available at
https://www.nmlegis.gov/Sessions/19%20Regular/bills/house/HB0090.pdf.
102 “Our Care, Our Choice Act,” 2018 Haw. Sess. Laws Act 2739, § 1, definition of “attending provider.”
103 NY A02383 “Medical Aid in Dying Act,” § 2899- e.1.
104 Oregon Senate Bill 579.
105 State of Maryland, Senate, End- of-Life Option Act, Maryland Senate Bill 311, http://mgaleg.maryland.gov/
2019RS/bills/sb/sb0311f.pdf.
106 Compassion & Choices, “Seriously Ill Advocates for MD End- of-Life Option Act Express Concerns
That Reported Bill Amendments May Endanger Passing Law This Year,” March 14, 2019, https://
compassionandchoices.org/news/seriously- ill- advocates- for- md- end- of- life- option- act- express- concerns-
that- reported- bill- amendments- may- endanger- passing- law- this- year/.
107 Maryland State Senators Bobby Zirkin et. al, “‘Compassion’ Lobby Says Evaluating Mental Illness Is
‘Excessive,’” March 14, 2019, a statement cited by Maryland Against Physician Assisted Suicide, https://
stopassistedsuicidemd.org/compassion- lobby/.
108 Patients Rights Council, see generally, The Netherlands, http://www.patientsrightscouncil.org/site/holland/,
Belgium, http://www.patientsrightscouncil.org/site/?s=belgium&cat=0&submit=Search, Canada, http://www
.patientsrightscouncil.org/site/?s=Canada&cat=0&submit=Search. Also, Australian Care Alliance, “Fifteen
Fatally Flawed Experiments,” https://www.australiancarealliance.org.au/flawed_experiments.
109 Rita Marker, interview.
110 Patients Rights Council, see generally, The Netherlands, http://www.patientsrightscouncil.org/site/holland/,
Belgium, http://www.patientsrightscouncil.org/site/?s=belgium&cat=0&submit=Search, Canada, http://www
.patientsrightscouncil.org/site/?s=Canada&cat=0&submit=Search. Also, Australian Care Alliance, “Fifteen
Fatally Flawed Experiments,” https://www.australiancarealliance.org.au/flawed_experiments.
111 Both euthanasia and assisted suicide have been widely practiced in the Netherlands since 1973, although
they were against the law until 2002. The Dutch situation between 1973 and 2002 was an outgrowth of a
series of court decisions and medical association guidelines, beginning with a 1973 District Court case in
which Geertruida Postma, a Dutch physician, was convicted of the crime of euthanasia after she ended the
64 National Council on Disability
life of her seriously ill mother. See Nederlandse Jurisprudentie 1973, no. 183, District Court of Leeuwarden,
21, February 21, 1973; translation in Walter Lagerway, Issues in Law and Medicine, 3 (1988): 429, 439–42.
Her admission that she had given her mother a lethal injection seemed calculated to force public and legal
reconsideration of the laws against assisted suicide (Penal Code of the Netherlands, §294) and euthanasia
(Penal Code of the Netherlands, §293). While finding Dr. Postma guilty of the crime of mercy killing that was
punishable by imprisonment for a maximum of 12 years, the court imposed a 1- week suspended sentence
and a week’s probation. The Dutch court relied heavily on expert testimony by the District’s medical inspector
who set forth certain conditions “under which the average physician thought euthanasia should be considered
acceptable.” Inclusion of those conditions formed the basis for subsequent acceptance of euthanasia and
assisted suicide in the Netherlands. The guidelines required that the patient must be considered incurable
and experiencing subjectively unbearable suffering; the request for termination of life should be in writing;
and there should be adequate consultation with other physicians before death could be induced. See Carlos
Gomez, Regulating Death: Euthanasia and the Case of the Netherlands (Old Tappan, NJ: Free Press, 1991),30.
Other cases followed, each widening the boundaries and further liberalizing the conditions under which
euthanasia and assisted suicide, although remaining illegal, would not be punished. Among the cases was
the Alkmaar case (Nederlandse Jurisprudentie 1985, no. 106) in which a woman died after requesting death
because “her advancing age and physical condition caused her to be dependent on others, thus leading
to psychological suffering.” The case gave rise to the 1986 decision by the Hague Court of Appeals that
recognized “psychic suffering” and “potential disfigurement of personality” as grounds for induced death.
The courts have also exonerated physicians who assisted in the suicides of a young woman with anorexia
nervosa (Amelo, Tijdschrift voor Gezondheidsrecht, 1992, No. 19) and a woman who was depressed over the
death of her two children and the failure of her marriage (Assen, Nederlandse Jurisprudentie, 1994, No. 656).
This discussion is drawn from the International Task Force on Euthanasia and Assisted Suicide, Assisted
Suicide & Death with Dignity: Past, Present & Future—Part III, International Perspective, available at http://
www.internationaltaskforce.org/rpt2005_3.htm (accessed July 13, 2009). For additional discussion of these
and other cases, see Gomez, Regulating Death; I. J. Keown, “The Law and Practice of Euthanasia in the
Netherlands,” Law Quarterly Review 108 (1992): 51–52; Herbert Hendin, Seduced by Death: Doctors, Patients,
and Assisted Suicide (New York: Norton, 1997); and Jonathan T. Smies, “The Legalization of Euthanasia in the
Netherlands,” Across Borders International Law Journal, 7 (2004).
112 “Doctors had reported that a total of 2,146 people were euthanized and 152 died in assisted suicides in
2008, while in 33 cases there was a combination of the two practices.” See Expatica.com, “Dutch Court Jails
Euthanasia Group Chairman for Aiding Suicide,” May 30, 2009.
113 Hendin further testified, “In 13 percent of these cases, physicians who did not communicate with competent
patients concerning decisions that might or were intended to end their lives gave as a reason for not doing so
that they had previously had some discussion of the subject with the patient. Yet it seems incomprehensible
that a physician would terminate the life of a competent patient on the basis of some prior discussion without
checking if the patient still felt the same way.” Herbert Hendin, MD, Suicide, Assisted Suicide and Euthanasia:
Lessons from the Dutch Experience, Testimony Summary, US House of Representatives, Subcommittee on
the Constitution, April 29, 1996. Also, Hendin has written that, for over a thousand people each year in the
Netherlands, physicians have ended their patients’ lives without consulting the patients. “The most alarming
concern has been the documentation of [a] thousand cases a year in which patients who have not given their
consent have their lives ended by physicians. A quarter of [the] physicians stated that they ‘terminated the
lives of patients without an explicit request’ from the patient. Another third of the physicians could conceive
of doing so.” Herbert Hendin, MD, “Commentary: The Case Against Physician-Assisted Suicide: For the Right
to End- of-Life Care,” Psychiatric Times 21, no. 2, February 1, 2004, available at http://www.psychiatrictimes
.com/display/article/10168/54071.
114 Herbert Hendin, MD, Lessons from the Dutch Experience, Testimony to Subcommittee on the Constitution.
The Danger of Assisted Suicide Laws 65
115 Diane Coleman, JD, “Not Dead Yet,” in The Case Against Assisted Suicide—For the Right to End- of-Life Care,
ed. Kathleen Foley and Herbert Hendin (Baltimore: The Johns Hopkins University Press, 2002), 221.
116 “In 2010, the age- adjusted suicide rate among Oregonians of 17.1 per 100,000 was 41 percent higher than
the national average.” Oregon Health Authority, Public Health Division, Suicides in Oregon: Trends and Risk
Factors—2012 Report, November 2012, 1.
117 David Albert Jones and David Paton, “How Does Legalization of Physician-Assisted Suicide Affect Rates
of Suicide?” Southern Medical Journal, October 10, 2015,
http://sma.org/southern- medical- journal/article/
how- does- legalization- of- physician- assisted- suicide- affect- rates- of- suicide/.
118 Aaron Kheriaty, “The Dangerously Contagious Effect of Assisted-Suicide Laws,” Washington Post, November
20, 2015,
https://www.washingtonpost.com/opinions/the- dangerously- contagious- effect- of- assisted- suicide-
laws/2015/11/20/6e53b7c0-83fb-11e5- a7ca-6ab6ec20f839_story.html?utm_term=.50c61d657eef. Aaron
Kheriaty is an associate professor of psychiatry and director of the medical ethics program at the University of
California at Irvine School of Medicine.
119 State of Connecticut, “State of Connecticut Suicide Prevention Plan 2020,” accessed March 12, 2019,
https://www.sprc.org/sites/default/files/Conn_Suicide-Prevention-Plan-2020.pdf.
120 Roger J. Stancliffe, Michele Y. Wiese, and Sue Read, “End of Life and People with Intellectual Disability,”
JARID Editorial, June 13, 2017, https://onlinelibrary.wiley.com/doi/abs/10.1111/jar.12383. Also see American
Association on Intellectual and Developmental Disabilities (AAIDD), “Caring at the End of Life—Position
Statement,”
https://aaidd.org/news- policy/policy/position- statements/caring- at- the- end- of- life.
121 Olmstead v. L.C., 527 US 581 (1999).
122 Pew Research Center, “Views on End- of-Life Medical Treatments,” November 21, 2013, https://www
.pewforum.org/2013/11/21/views- on- end- of- life- medical- treatments/. A related source is Patricia K. Jennings
and Clarence R. Talley, “A Good Death?: White Privilege and Public Opinion: Research on Euthanasia,” Race,
Gender & Class 10, no. 3 (2003): 42–63, http://www.jstor.org/stable/41675087.
123 Oregon Death with Dignity Act, 2018 Data Summary.
124 Pew Research Center, “Views on End- of-Life Medical Treatments.”
125 Anita Cameron, “Testimony Opposing New York Assisted Suicide Bill A2383A.”
126 Alexei Koseff and Jeremy B. White, “California Assisted Death Bill Appears Finished for the Year,” Sacramento
Bee, July 7, 2015,
https://www.sacbee.com/news/politics- government/capitol- alert/article26660032.html.
127 Fenit Nirappil, “Right- to-Die Law Faces Skepticism in Nation’s Capital: ‘It’s Really Aimed at Old Black People,’”
Washington Post, October 17, 2015, https://www.washingtonpost.com/local/dc- politics/right- to- die- law-
faces- skepticism- in- us- capital- its- really- aimed- at- old- black- people/2016/10/17/8abf6334-8ff6-11e6- a6a3-
d50061aa9fae_story.html?utm_term=.9b1a7dc625d1.
128 Lydia S. Dugdale, “Will Black Lives Still Matter to Death with Dignity Act?” The Hill, January 23, 2017,
https://thehill.com/blogs/pundits- blog/healthcare/315731- will- black- lives- matter- to- death- with- dignity- act.
129 AMA meeting, “AMA OKs Palliative Sedation for Terminally Ill,” American Medical News, July 7, 2008. Also
Timothy W. Kirk, Ph.D., and Margaret M. Mahon, Ph.D., RN, FAAN, “National Hospice and Palliative Care
Organization (NHPCO) Position Statement and Commentary on the Use of Palliative Sedation in Imminently
Dying Terminally Ill Patients,” Journal of Pain and Symptom Management 39, no. 5 (May 2010), DOI: 10.1016/
j.jpainsymman.2010.01.009.
130 Anita Cameron, “The Criminalization of Pain,” October 4, 2018, http://notdeadyet.org/2018/10/anita- cameron-
the- criminalization- of- pain.html. Anita Cameron is the Director of Minority Outreach for Not Dead Yet.
131 John Heubusch, “The War on Opioids Is Saving Lives. But It’s Also Killing People Like Me,” Washington Post,
March 27, 2019, https://www.washingtonpost.com/opinions/the-war-on-opioids-is-saving-lives-but-its-also-killing-
people-like-me/2019/03/27/cea00af6-50c2-11e9-a3f7-78b7525a8d5f_story.html?utm_term=.b0278d4daad0.
Also Kate Nicholson, “The Other Side of the Opioid Epidemic—We’re People in Severe Pain,” The Hill,
February 16, 2018, https://thehill.com/opinion/healthcare/374246-the-other-side-of-the-opioid-epidemic-were-
people-in-severe-pain. Also Will Stone, “Patients with Chronic Pain Feel Caught in an Opioid-Prescribing
66 National Council on Disability
Debate,” Kaiser Health News, August 1, 2018, https://www.healthleadersmedia.com/clinical-care/
patients-chronic-pain-feel-caught-opioid-prescribing-debate.
132 S. A. Fohr, “The Double Effect of Pain Medication: Separating Myth from Reality,” Journal of Palliative
Medicine 1 (1998): 315–26; T. A. Curry,” What Would Mom Want?” JAMA 315 (2016): 261–62.
133 Ohio State, “Core Competence on Disability for Healthcare Education,” April 2018, accessed March 5, 2019,
http://nisonger.osu.edu/wp-content/uploads/2018/09/Core-Competencies-on-Disability_8.31.18.pdf.
The Danger of Assisted Suicide Laws 67
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