To view a pdf version, click these links for the index, memo and appendix.
The issues addressed include why proposed patient protections ("safeguards") are unenforceable. See Section IX below.
Margaret Dore, Esq., MBA
I. INTRODUCTION
I am an attorney in Washington State where assisted suicide is legal. Our law is based on a similar law in Oregon.[1] Both laws are similar to SB 261, which seeks to legalize assisted suicide and euthanasia in Nevada.[2]
SB 261 is stacked against the individual and recipe for elder abuse. If enacted, the bill will encourage people with years or decades to live to throw away their lives. I urge you to reject this measure.
II. DEFINITIONS
A. Physician-Assisted Suicide; Assisted Suicide; and Euthanasia
The American Medical Association (AMA) defines physician-assisted suicide as occurring when “a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act.”[3] For example:
[T]he physician provides sleeping pills and information about the lethal dose, while aware that the patient may commit suicide.[4]Assisted suicide is a general term in which an assisting person is not necessarily a physician. Euthanasia is the administration of a lethal agent to cause another person’s death.[5]
B. Withholding or Withdrawing Treatment
Withholding or withdrawing treatment (“pulling the plug”) is not euthanasia if the purpose is to remove burdensome treatment, as opposed to an intent to kill the patient. More importantly, the patient will not necessarily die. Consider this quote from Washington State regarding a man removed from a ventilator:
[I]nstead of dying as expected, [he] slowly began to get better.[6]III. THE STATES PUSH BACK AGAINST ASSISTED SUICIDE
A. This Year, the South Dakota Legislature Passed a Nearly Unanimous Resolution Opposing Assisted Suicide
This year, the South Dakota Legislature passed Senate Concurrent Resolution 11, opposing physician-assisted suicide.[7] The vote was nearly unanimous.[8]
B. Last Year, the New Mexico Supreme Court Overturned Assisted Suicide in New Mexico
Last year, the New Mexico Supreme Court overturned a lower court decision that had recognized a right to physician aid in dying, meaning physician assisted suicide.[9] Physician-assisted suicide is no longer legal in New Mexico.
C. Five Other States Have Strengthened Their Laws Against Assisted Suicide
In the last six years, five other states have strengthened their laws against assisted suicide. These states are Arizona, Louisiana, Georgia, Idaho and Ohio.[10]
IV. THE OREGON AND WASHINGTON LAWS
Oregon and Washington State legalized assisted suicide via ballot measures in 1997 and 2008, respectively. In the fine print, these laws also allow euthanasia.
V. ELDER ABUSE
Elder abuse is a problem throughout the United States, including Nevada.[11] Perpetrators are often family members who start out with small crimes, such as stealing jewelry and blank checks, before moving on to larger items or to coercing victims to change their wills or to liquidate their assets.[12] Victims are sometimes murdered.[13]
Perpetrators can also be calculating criminals. Consider Melissa Ann Shepard, the “Internet Black Widow” who preyed on older men. A 2016 article states:
[These men] sought companionship and found instead . . . someone who siphoned their savings, slipped drugs into their food and, in the case of one man, ran him over with a car and left him dead on a dirt road. (Emphasis added)[14]VI. HOW THE BILL WORKS
The bill has an application process to obtain the lethal dose, which includes a lethal request form with two required witnesses.[15] One of the witnesses is allowed to be the patient’s heir who will financially benefit from the patient’s death.[16]
After the lethal dose is issued by the pharmacy, there is no oversight. No doctor, not even a witness, is required to present at the death.[17]
VII. A COMPARISON TO PROBATE LAW
When signing a will, having an heir act as a witness can support a finding of undue influence. Washington State’s probate code, for example, provides that when one of two witnesses receives a gift under a will, there is a presumption that the gift was procured “by duress, menace, fraud, or undue influence."[18] The proposed bill, which allows an heir to act as a witness on the lethal dose request form, invites coercion.
VIII. YEARS OR DECADES TO LIVE
SB 261 applies to persons with a “terminal condition,” meaning those predicted to have less than six months to live. Such persons may, in fact, have years or decades to live. This is true for three reasons.
A. If Nevada Follows Oregon’s Interpretation of “Terminal Condition,” the Bill Will Apply to People with Chronic Conditions Such as Insulin Dependent Diabetes
SB 261 states:
“Terminal condition” means an incurable and irreversible condition that cannot be cured or modified by any known current medical therapy or treatment and which will, in the opinion of the attending physician, result in death within 6 months.[19]Oregon’s law has a similar definition:
“Terminal disease” means an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.[20]In Oregon, this similar definition is interpreted to include chronic conditions such as “diabetes mellitus,” better known as diabetes.[21] Oregon doctor, William Toffler, explains:
[P]eople with chronic conditions are “terminal” [for the purpose of Oregon’s law] if without their medications, they have less than six months to live. This is significant when you consider that a typical insulin-dependent 20 year-old will live less than a month without insulin.[22]Dr. Toffler adds:
Such persons, with insulin, are likely to have decades to live; in fact, most diabetics have a normal life span given appropriate control of their blood sugar.[23]Dr. Toffler also addresses the Nevada definition, as follows:
[T]he Nevada definition also applies to [patients] with chronic conditions such as insulin dependent diabetes. This is because treatments such as insulin do not reverse, cure or modify the underlying disease or condition. . . .
Patients, instead, are able to function [with treatment]. This is especially true with diabetes in which treatment with insulin can allow [patients] to live happy, healthy and productive lives.[24]If Nevada enacts SB 261, the bill as written will allow assisted suicide and euthanasia for people with chronic conditions such as insulin dependent diabetes. Such persons can have years or decades to live.
B. Predictions of Life Expectancy Can Be Wrong
Eligible persons may also have years to live because predictions of life expectancy can be wrong.[25]
Consider John Norton, who was diagnosed with ALS (Lou Gehrig’s disease) at age 18.[26] He was told that he would get progressively worse (be paralyzed) and die in three to five years.[27] Instead, the disease progression stopped on its own.[28] In a 2012 affidavit, at age 74, he states:
If assisted suicide or euthanasia had been available to me in the 1950's, I would have missed the bulk of my life and my life yet to come.Affidavit of John Norton, at A-18, ¶ 5.
C. Treatment Can Lead to Recovery
Consider also, Jeanette Hall, who was diagnosed with cancer in 2000 and made a settled decision to use Oregon’s law.[29] Her doctor convinced her to be treated instead.[30] In a 2016 declaration, she states:
This July, it will be 16 years since my diagnosis. If [my doctor] had believed in assisted suicide, I would be dead.[31]If the bill is enacted, people like Jeanette Hall, with years or decades to live, will be encouraged to throw away their lives.
IX. INDIVIDUAL CHOICE IS NOT ASSURED
A. Voluntariness and Consent Are Not Required When the Lethal Dose is Administered
The bill does not require administration of the lethal dose to be voluntary.[32] There is also no language requiring consent to administration.[33] Without these requirements, patient choice and control is far from guaranteed.
B. “Self-Administer” Does Not Mean Voluntary or Consensual
The bill refers to the lethal dose as being “self-administered,” which is not a defined term.[34] The term’s ordinary meaning, to administer to oneself, is a different concept than voluntary or consensual conduct. Consider, for example, a person already intoxicated on alcohol, who drinks another shot without being aware that it contains the lethal dose. He or she would be self-administering the lethal dose, but would not be engaging in voluntary or consensual conduct.
Without a requirement of voluntary and consensual conduct by the patient to administer the lethal dose, patient choice and control is not guaranteed.
C. "Even If a Patient Struggled, Who Would Know?"
The bill has no required oversight over administration of the lethal dose.[35] In addition, the drugs used are water and or alcohol soluble, such that they can be injected into a sleeping or restrained person without consent.[36] Alex Schadenberg, Executive Director for the Euthanasia Prevention Coalition, puts it this way:
With assisted suicide laws in Washington and Oregon [and with SB 261], perpetrators can . . . take a “legal” route, by getting an elder to sign a lethal dose request. Once the prescription is filled, there is no supervision over administration. Even if a patient struggled, “who would know?” (Emphasis added).[37]D. The Bill Merely Requires That Actions Be Taken in “Accordance” with its Provisions; Compliance With Patient Protections Is Not Required
The bill describes patient protections in sections 3 to 26, as follows:
The provisions of sections 3 to 26, inclusive, of this act are intended to provide the safeguards, procedures, written requirements and reporting functions to allow a safe framework for patients . . . . (Emphasis added).[38]The bill also describes events in “accordance” with sections 3 to 26. For example, the bill states:
Death resulting from a patient self- administering a controlled substance that is designed to end his or her life in accordance with the provisions of sections 3 to 26, inclusive, of this act does not constitute suicide or homicide. (Emphasis added). [39]The bill does not define “accordance.”[40] Dictionary definitions include “in the spirit of,” meaning “in thought or intention.”[41] With these definitions, a mere thought to comply with patient protections is enough. Compliance is not required.
For these reasons also, patient choice and control are not guaranteed.
E. If Nevada Follows Washington State, There Will Be an Official Legal Cover Up; Compliance with Patient Protections Will Be Irrelevant
The bill states:
The medical certificate of death of a patient who dies after self-administering a controlled substance that is designed to end the life of the patient in accordance with the provisions of sections 3 to 26, inclusive, of this act must be signed by the attending physician who shall specify the terminal condition with which the patient was diagnosed as the cause of death of the patient. (Emphasis added).[42]
[and]
Death resulting from a patient self-administering a controlled substance that is designed to end his or her life in accordance with the provisions of sections 3 to 26, inclusive, of this act does not constitute suicide or homicide. (Emphasis added).[43]In Washington State, similar, albeit less wordy language is interpreted by the Washington State Department of Health to require the death certificate to list a terminal disease as the cause of death, without even a hint that the actual cause of death was assisted suicide or euthanasia. The only relevant inquiry is whether Washington’s act was “used.” Compliance with patient protections is not required.
The Washington State Department of Health, “Death Certificate Instructions for Medical Examiners, Coroners and Prosecuting Attorneys,” state:
Washington’s [law] states that “...the patient’s death certificate ... shall list the underlying terminal disease as the cause of death.” [Washington’s law] also states that, “Actions taken in accordance with this chapter do not, for any purpose, constitute suicide, assisted suicide, mercy killing, or homicide under the law.”
If you know the decedent used [Washington’s law], you must comply with the strict requirements of the law when completing the death record:
1. The underlying terminal disease must be listed as the cause of death. . . .
3. The cause of death section may not contain any language that indicates that [the law] was used, such as:
a. SuicideIf Nevada enacts the proposed bill and follows Washington State, death certificates will list a terminal condition without even a hint that the actual cause of death was assisted suicide or euthanasia. This will be without regard to whether there was compliance with patient protections. There will be an official legal cover up.
b. Assisted suicide
c. Physician-assisted suicide
d. Death with Dignity
e. I-1000 [Washington’s law was passed by I-1000]
f. Mercy killing
g. Euthanasia
h. Secobarbital or Seconal
i. Pentobarbital or Nembutal (Emphasis added.)[44]
F. The Death Certificate Will List a Terminal Condition as the Cause of Death, Which Will Prevent Prosecution for Murder
The bill states:
The medical certificate of death of a patient who dies after self-administering a controlled substance that is designed to end the life of the patient in accordance with the provisions of sections 3 to 26, inclusive, of this act must be signed by the attending physician who shall specify the terminal condition with which the patient was diagnosed as the cause of death of the patient. (Emphasis added).[45]The significance of requiring a terminal condition to be listed as the cause of death is that it creates a legal inability to prosecute. The official legal cause of death is a terminal condition (not murder) as a matter of law.
More to the point, a perpetrator will be let off the hook: The bill will create the perfect crime.
X. OREGON IS NOT A VALID CASE STUDY
Oregon is not a valid case study due to a near complete lack of transparency regarding its law.[46] Even law enforcement does not have access to the information collected.[47] Source documentation is destroyed.[48] The bottom line, Oregon’s official data cannot be verified.
XI. PROPOSED GOVERNMENT OVERSIGHT IS A SHAM
The bill provides for data collection similar to Oregon in which patient names and other identifying patient data will not be provided to “oversight” authorities.”[50] As with Oregon, there will be little, if any, ability to verify reported data. The proposed government oversight is a sham.
XII. TRAUMA
A. The Swiss Study: Physician-Assisted Suicide Can Be Traumatic for Family Members
In 2012, a European research study addressed trauma suffered by persons who witnessed legal physician-assisted suicide in Switzerland.[51] The study found that one out of five family members or friends present at an assisted suicide was traumatized. These people,
experienced full or sub-threshold PTSD (Post Traumatic Stress Disorder) related to the loss of a close person through assisted suicide.[52]B. My Clients Suffered Trauma in Oregon and Washington State
In Washington State and Oregon, I have had two cases where my clients suffered trauma due to legal assisted suicide. In the first case, one side of the family wanted the father to take the lethal dose, while the other side did not. The father spent the last months of his life caught in the middle and torn over whether or not he should kill himself. My client, his adult daughter, was severely traumatized. The father did not take the lethal dose and died a natural death.
In the other case, it’s not clear that administration of the lethal dose was voluntary. A man who was present told my client that his (my client's father) had refused to take the lethal dose when it was delivered, stating, "You're not killing me. I'm going to bed," but then he (the father) took it the next night when he was intoxicated on alcohol. The man who told this to my client subsequently changed his story.
My client, although he was not present, was traumatized over the incident, and also by the sudden loss of his father.
XIII. SUICIDE CONTAGION
Government reports from Oregon show a positive statistical correlation between the legalization of physician-assisted suicide and an increase in other (conventional) suicides. This statistical correlation is consistent with a suicide contagion in which legalizing physician-assisted suicide encouraged other suicides. Consider the following:
Oregon's assisted suicide act went into effect “in late 1997.”[53]
By 2000, Oregon's conventional suicide rate
was "increasing significantly."[54]
By 2007, Oregon's conventional suicide rate was 35% above the national average.[55]
By 2010, Oregon's conventional suicide rate was 41% above the national average.[56]
By 2012, Oregon's conventional suicide rate was 42% above the national average.[57]There is a significant financial cost associated with these other suicides. One reason is that people who attempt suicide (and fail) can injure themselves or become disabled by the attempt. A government report from Oregon states:
[T]he estimate of total lifetime cost of suicide in Oregon was over 680 million dollars.[58]XIV. UNDUE INFLUENCE
The bill has a felony for “undue influence,” which is not defined. The bill, § 24(b)(1), states:
It is unlawful for any person to: . . . .As noted supra, the bill also allows a patient’s heir to be a witness on the lethal dose request form, which is a marker of undue influence in the context of a will.[60]
(b) Coerce or exert undue influence on a person to:
(1) Request a controlled substance that is designed to end the life of the person . . . .(Emphasis added)[59]
How do you prove that undue influence occurred when the bill does not define it and the bill also allows conduct used to prove it in another context? You can’t. The felony for undue influence is illusory and unenforceable.
XV. CONCLUSION
Passing SB 261 will encourage people with years or decades to live to throw away their lives. Elder abuse is already a problem. Passage of the bill will make it worse.
The bill is sold as voluntary, but does not even have a provision requiring administration of the lethal dose to be voluntary. Administration of the lethal dose is allowed to occur in private without a doctor or witness present. If the patient objected, or even struggled, who would know?
The death certificate will list a terminal condition as the cause of death. This will prevent prosecution for murder, no matter what the facts. The bill, if passed, will create the perfect crime.
I urge you to vote “No” on SB 261.
Respectfully Submitted,
Margaret Dore, Esq., MBA
Unpaid Volunteer Lobbyist
Law Offices of Margaret K. Dore, P.S.
Choice is an Illusion, a nonprofit corporation
www.margaretdore.com
www.choiceillusion.org
1001 4th Avenue, Suite 4400
Seattle, WA 98154
206 697 1217
Footnotes:
[1] I am an elder law and appellate attorney licensed to practice law in Washington State since 1986. I am also president of Choice is an Illusion, a nonprofit corporation opposed to assisted suicide and euthanasia. My CV is attached in the appendix at A-1 to A-4. See also www.margaretdore.com and www.choiceillusion.org
[2] SB 261 (First Reprint) is attached in the appendix at A-101 through A-126.
[3] The AMA Code of Medical Ethics, Opinion 5.7, attached in the appendix at A-5.
[4] Id.
[5] Id, Opinion 5.8, “Euthanasia,” attached in the appendix at A-5 (lower half of the page).
[6] Nina Shapiro, “Terminal Uncertainty — 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 Seattle Weekly, 01/14/09; article in the appendix at A-6, quote at A-8.
[7] Bill History, South Dakota Senate Concurrent Resolution 11, “Opposing physician-assisted suicide,” attached in the appendix at A-9.
[8] Id., 32 to 3 in the Senate; 67 to 1 in the House.
[9] Morris v. Brandenburg, 376 P.3d 836 (2016). (Excerpt attached in the appendix at A-12).
[10] See: AP, “Brewer signs law targeting assisted suicide,” Arizona Capitol Times, 04/30/14, attached in the appendix at A-13; AP, “La. assisted-suicide ban strengthened,” The Daily Comet, 04/24/12, attached in the appendix at A-14; Georgia HB 1114, attached in the appendix at A-15; “Idaho Strengthens Law Against Assisted Suicide,” attached in the appendix at A-16 (”The law explicitly provides that causing or aiding a suicide is a felony”); and Ohio HB 470, at https://choiceisanillusion.files.wordpress
[11] See: Met Life Mature Market Institute, Broken Trust: Elders, Family and Finances,” March 2009, at https://www.metlife.com/assets/cao/mmi/publications/studies/mmi-study-broken-trust-elders-family-finances.pdf; Geoff Dornan, “Working to stop senior exploitation,” Nevada Appeal, June 25, 2015, attached in the appendix at A-18 to A-19; and elder abuse info sheet, attached in the appendix at A-10.
[12] Id.
[13] Met Life, supra.
[14] Yanan Wang, “This 80-year-old ‘Black Widow,’ who lured lonesome old men to horrible fates, is out of prison again,” The Washington Post, March 21, 2016. (Attached in the appendix at A-20 through A-22; quote at A-21).
[15] The bill’s lethal dose request form can be viewed at § 13, attached in the appendix at A-107 to A-108. The witness section can be viewed at A-108.
[16] SB 261, § 13, attached in the appendix at A-108.
[17] See SB 261 in its entirety, attached in the appendix at A-101 to A-126.
[18] Wash. Rev. Code Ann. § 11.12.160(2), attached in the appendix at A-11.
[19] SB 261, § 10, attached in the appendix at A-105, lines 23 to 27.
[20] Or. Rev. Stat. 127.800 s.1.01(12), attached in the appendix at A-27.[21] See Declaration of William Toffler, MD, in the appendix at A-24 to A-25, ¶¶ 2-4.
[22] Id., in the appendix at A-25, ¶ 5.
[23] Id., at ¶ 6.
[24] Id., ¶¶ 8 & 9.
[25] See Jessica Firger, “12 million Americans misdiagnosed each year,” CBS NEWS, 4/17/14, attached in the appendix at A-31, and Nina Shapiro, “Terminal Uncertainty — 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 Seattle Weekly, 01/14/09. (Excerpts attached in the appendix at A-6 to A-8).
[26] Affidavit of John Norton, attached in the appendix at A-17 to A-19.
[27] Id., ¶ 1.
[28] Id., ¶ 4, attached in the appendix at A-18.
[29] Affidavit of Kenneth Stevens, MD, attached in the appendix at A-31 to A-37; Jeanette Hall discussed at A-31 to A-32; Hall declaration attached in the appendix at A-38.
[30] Id.
[31] Declaration of Jeanette Hall, ¶4, in the appendix at A-38.
[32] The bill uses the word “voluntary” in relation to a request for the lethal dose, not administration. See SB 261 in its entirety, attached in the appendix at A-104, line 16 to A-126, line 18.
[33] The bill uses the word, “consent” just once, in the context of the obtaining the lethal dose from a pharmacist, not administration. See the bill, § 16.2, which merely states:
After an attending physician prescribes a controlled substance that is designed to end the life of a patient, the attending physician shall, with the written consent of the patient, contact a pharmacist and inform the pharmacist of the prescription. After the pharmacist has been notified, the attending physician shall give the prescription directly to the pharmacist or electronically transmit the prescription directly to the pharmacist. (Emphasis added).Attached in the appendix at A-110, lines 15-21.
[34] See SB 261, §§ 3-10, attached at A-104, line 44 to A-105, line 27.
[35] See SB 261 in its entirety, attached in the appendix at A-104, line 16
[36] In Oregon, the drugs used include Secobarbital, Pentobarbital (Nembutal) and Phenobarbital. See the Oregon government report excerpts, attached in the appendix at A-41 and A-42 (listing these drugs). Secobarbital and Pentobarbital are soluble in water and alcohol. See http://www.drugs.com/pr/seconal-sodium.html and http://www.drugs.com/pro/nembutal.html. Phenobarbital is soluble in alcohol. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2977013
[37] Alex Schadenberg, Letter to the Editor, “Elder abuse a growing problem,” The Advocate, Official Publication of the Idaho State Bar, October 2010, page 14, available at http://www.margaretdore.com/info/October_Letters.pdf.
[38] SB 261, § 10.5.4, attached in the appendix at A-105, line 43 to A-106, line 2.
[39] Id., § 22.1. The bill uses this same "accordance" language throughout its text.
[40] See SB 261 in its entirety, attached in the appendix at A-101 to A-126.
[41] See “accordance” definition attached in the appendix at A-42, and “in the spirit” definition attached hereto at A-67.
[42] SB 261, § 1.3, attached in the appendix at A-104, lines 35-40.
[43] SB 261, § 22.1, attached in the appendix at A-113, lines 40 to 43.
[44] A copy of the Washington State Death certificate is attached in the appendix at A-43.
[45] SB 261, § 1.3, attached in the appendix at A-104, lines 35-40.
[46] See: “Declaration of Testimony” by Oregon attorney Isaac Jackson, dated September 18, 2012, attached in the appendix at A-45 to A-50 (regarding the run-around he got when he attempted to learn whether his client’s father had died under Oregon’s law - the Oregon Health Authority would neither confirm nor deny whether the father had died under the law); E-mail from Alicia Parkman, Oregon Mortality Research Analyst, to Margaret Dore, dated January 4, 2012, attached at A-51 to A-52 (law enforcement cannot get access to information); Excerpt from Oregon’s website at A-53 (patient identities “not recorded in any manner”); E-mail from Parkman to Dore, June 27, 2011, attached at A-55 to A-56 (“all source documentation” destroyed after one year); and the "Confidentiality of Death Certificates" policy issued by the Oregon Department of Human Resources Health Division, December 12, 1997, (clarifying that employees failing to comply with confidentiality rules “will immediately be terminated”), as published in the Issues in Law & Medicine, Volume 14, Number 3, 1998.
[47] Id.
[48] Id.
[50] See SB 261, §§ 20 & 20.5, attached in the appendix at A-112 & A-113.
[51] “Death by request in Switzerland: Posttraumatic stress disorder and complicated grief after witnessing assisted suicide,” B. Wagner, J. Muller, A. Maercker; European Psychiatry 27 (2012) 542-546, available at http://choiceisanillusion.files.wordpress.com/2012/10/family-members-traumatized-eur-psych-2012.pdf (Cover page attached in the appendix at A-57).
[52] Id., at A-57.
[53] Oregon’s assisted suicide report for 2014, first line, at http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf
[54] See Oregon Health Authority News Release, 09/09/10. ("After decreasing in the 1990s, suicide rates have been increasing significantly since 2000"). (Attached in the appendix at A-60).
[55] Report excerpts at A-61 & A-62.
[56] Oregon Health Authority Report, attached in the appendix at A-63 & A-64.
[57] Attached in the appendix at A-65.
[58] See report at A-.
[59] Attached in the appendix at A-114.
[60] Again, see Washington State’s probate statute attached in the appendix at A-11