Suicide prevention plans at odds with right to die

This Canadian article is consistent with the Oregon experience in which legalization of physician-assisted suicide was followed by a significant increase in other suicides.  See footnote 1.

http://www.calgaryherald.com/opinion/op-ed/Martinuk+Suicide+prevention+plans+odds+with+right/9343852/story.html

By Susan Martinuk, Calgary Herald January 3, 2014 

Retired politician Bob Rae used the occasion of a friend's apparent suicide to call on Canada to establish a national suicide prevention plan.

Susan Martinuk

Chris Peloso was Rae's friend and well known in Ontario's political circles as the husband to George Smitherman, a former high-profile cabinet minister and politician. Media reports haven't utilized the term suicide, but the phrase "lost his battle with depression" seems to indicate that was the case.

Calls for such a strategy are made every time there is a high-profile suicide in this country (such as Amanda Todd and Rehtaeh Parsons, two girls who suffered unbearable bullying in school and on the Internet). Parliament passed a suicide prevention strategy one year ago, but few seem to be aware of its existence or its implementation, and society continues to call for somebody to do something to prevent such tragedies from occurring.

Prevention is usually a good policy. But I have questions about whether any suicide prevention policy can be successful with Canada's health-care system and be consistent with other societal messages.

The first question is how can we effectively prevent suicides by those who are depressed when our health-care system offers limited (at best) access to psychiatric care and treatment?

A depressed person can call a suicide hotline or speak with a counsellor, and a crisis may be prevented. Or maybe not. But, at some point, the only way to prevent suicide is to access medical treatment.

The Fraser Institute's 2013 report, Waiting Your Turn: Wait Times for Health Care in Canada, reveals that the national average wait time from referral by a general practitioner to the time of beginning non-urgent psychiatric treatment was 20.3 weeks. If you live in New Brunswick, that wait is 73.5 weeks. That's about 1.5 years to access treatment and includes a 46-week wait from the time of GP referral to seeing a psychiatric specialist.

If you live in Saskatchewan, the wait for treatment is one year. Even if the case is urgent, patients still face a five-week wait to get an appointment with a psychiatrist. Anyone familiar with depression or other mental illnesses knows that a lot can change in five weeks, let alone one year.

Rae thinks it's important to have public conversations about mental illness. But awareness has absolutely nothing to do with treatment and, based on the above statistics, it's difficult to imagine that any province could maintain an effective suicide prevention strategy.

My second question raises an issue that Canadians may not be familiar with, but will undoubtedly face in the coming months as Quebec (and eventually the rest of Canada) debates the legalization of euthanasia.

That is, how can we credibly promote suicide prevention strategies at the same time as a large portion of society is publicly claiming they have a right to die? After all, euthanasia is supposedly about the right to self-determination when individuals are forced to live in circumstances that are unbearable.

At least that's how the conversation goes. The reality of legalization is very different, as we've seen in Belgium, the Netherlands, Switzerland and Oregon. Each of these has relaxed their laws to the point that depressed people can easily access euthanasia. As one bioethicist claims, euthanasia in these districts expands the options for the mentally ill and "empowers" them when they make the choice.

A 2005 study in the Journal of Clinical Oncology showed that almost one half (44 per cent) of requests for euthanasia were made by patients with depression. These authors started with the premise that terminally ill people who requested euthanasia were more accepting of death and that depression would therefore not be a factor. In contrast, they found that depressed patients were four times more likely to request death.

A report in Current Oncology in 2011 summarized euthanasia in the Netherlands by saying that in 30 years, it "has moved from euthanasia of people who are terminally ill, to euthanasia of those who are chronically ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress of mental suffering," and now to euthanasia of those over 70 who are simply "tired of living."

How do we talk about such facts while promoting a national suicide prevention policy? A society that knows the slippery slope of euthanasia and still accepts its legalization has no credibility in talking about suicide prevention for those with mental illness.

Susan Martinuk is a columnist based in Western Canada. Her column appears every Friday.

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[1]   This quote is from  page 17 of Vote No on SB 220:

Oregon’s suicide rate, which excludes suicide under Oregon’s physician-assisted suicide act, is 35% higher than the national average.  This rate has been "increasing significantly since 2000." Just three years prior, Oregon legalized physician-assisted suicide.  This increased suicide rate is consistent with a suicide contagion (legalizing one type of suicide encourag[ing] other suicides).  There is, regardless, a statistical correlation between these two events.

Washington's Assisted Suicide Act

Originally published as "'Death with Dignity':  What Do We Advise Our Clients?," King County Bar Bulletin, May 2009.  See here.

Margaret Dore, Esq.

A client wants to know about the new Death with Dignity Act, which legalizes physician-assisted suicide in Washington.¹ Do you take the politically correct path and agree that it's the best thing since sliced bread? Or do you do your job as a lawyer and tell him that the Act has problems and that he may want to take steps to protect himself?

Patient "Control" is an Illusion

The new act was passed by the voters as Initiative 1000 and has now been codified as Chapter 70.245 RCW.  During the election, proponents touted it as providing "choice" for end-of-life decisions. A glossy brochure declared, "Only the patient — and no one else — may administer the [lethal dose]."² The Act, however, does not say this — anywhere. The Act also contains coercive provisions. For example, it allows an heir who will benefit from the patient's death to help the patient sign up for the lethal dose.

How the Act Works

The Act requires an application process to obtain the lethal dose, which includes a written request form with two required witnesses.³ The Act allows one of these witnesses to be the patient's heir.⁴ The Act also allows someone else to talk for the patient during the lethal-dose request process, for example, the patient's heir.⁵ This does not promote patient choice; it invites coercion.

Interested witness

By comparison, when a will is signed, having an heir as one of witnesses creates a presumption of undue influence. The probate statute provides that when one of the two required witnesses is a taker under the will, there is a rebuttable presumption that the taker/witness "procured the gift by duress, menace, fraud, or undue influence."⁶

Once the lethal dose is issued by the pharmacy, there is no oversight. The death is not required to be witnessed by disinterested persons. Indeed, no one is required to be present. The Act does not state that "only" the patient may administer the lethal dose; it provides that the patient "self-administer" the dose.

"Self-administer"

In an Orwellian twist, the term "self-administer" does not mean that administration will necessarily be by the patient. "Self-administer" is instead defined as the act of ingesting. The Act states, "'Self-administer' means a qualified patient's act of ingesting medication to end his or her life."⁷

In other words, someone else putting the lethal dose in the patient's mouth qualifies as "self-administration." Someone else putting the lethal dose in a feeding tube or IV nutrition bag also would qualify. "Self-administer" means that someone else can administer the lethal dose to the patient.

No witnesses at the death

If, for the purpose of argument, "self-administer" means that only the patient can administer the lethal dose himself, the patient still is vulnerable to the actions of other people, due to the lack of required witnesses at the death.

With no witnesses present, someone else can administer the lethal dose without the patient's consent. Indeed, someone could use an alternate method, such as suffocation. Even if the patient struggled, who would know? The lethal dose request would provide an alibi.

This situation is especially significant for patients with money. A California case states, "Financial reasons [are] an all too common motivation for killing someone."⁸ Without disinterested witnesses, the patient's control over the "time, place and manner" of his death, is not guaranteed.

If one of your clients is considering a "Death with Dignity" decision, it is prudent to be sure that they are aware of the Act's gaps.

What to Tell Clients

1. Signing the form will lead to a loss of control

By signing the form, the client is taking an official position that if he dies suddenly, no questions should be asked. The client will be unprotected against others in the event he changes his mind after the lethal prescription is filled and decides that he wants to live. This would seem especially important for clients with money. There is, regardless, a loss of control.

2. Reality check

The Act applies to adults determined by an "attending physician" and a "consulting physician" to have a disease expected to produce death within six months.⁹ But what if the doctors are wrong? This is the point of a recent article in The Seattle Weekly: Even patients with cancer can live years beyond expectations¹⁰. The article states:

Since the day [the patient] was given two to four months to live, [she] has gone with her children on a series of vacations . . . .

"We almost lost her because she was having too much fun, not from cancer," [her son chuckles].¹¹ 

Conclusion

As lawyers, we often advise our clients of worst-case scenarios. This is our obligation regardless of whether it is politically correct to do so. The Death with Dignity Act is not necessarily about dignity or choice. It also can enable people to pressure others to an early death or even cause it. The Act also may encourage patients with years to live to give up hope. We should advise our clients accordingly.

Margaret Dore is a Seattle attorney admitted to practice in 1986. She is the immediate past chair of the Elder Law Committee of the ABA Family Law Section. She is a former chair of what is now the King County Bar Association Guardianship and Elder Law Section. For more information, visit her website at www.margaretdore.com.

1 The Act was passed by the voters in November as Initiative 1000 and has now been codified as RCW chapter 70.245 [available at http://apps.leg.wa.gov/RCW/default.aspx?cite=70.245 ]

2 I-1000 color pamphlet, "Paid for by Yes! on 1000."

3 RCW 70.245.030 and .220 state that one of two required witnesses to the lethal-dose request form cannot be the patient's heir or other person who will benefit from the patient's death; the other may be.  [See http://www.margaretdore.com/pdf/C-SECTION-3_001.pdf]

4 id.

5 RCW 70.245.010(3) allows someone else to talk for the patient during the lethal-dose request process; for example, there is no prohibition against this person being the patient's heir or other person who will benefit from the patient's death. The only requirement is that the person doing the talking be "familiar with the patient's manner of communicating."

6 RCW 11.88.160(2).[http://www.margaretdore.com/pdf/D-RCW-11.12.160_001.pdf]

7 RCW 70.245.010(12).

8 People v. Stuart, 67 Cal. Rptr. 3rd 129, 143 (2007).

9 RCW 70.245.010(11) & (13).

10 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, January 14, 2009. http://www.seattleweekly.com/2009-01-14/news/terminal-uncertainty [or formatted versions here and here - the second version is more clear, but has an advertisement that may be objectionable to some viewers]

11 id.

"It wasn't the father saying that he wanted to die"

My wife and I operate two adult family homes in Washington State where assisted suicide is legal. I am writing to urge you to not make Washington's mistake.

Our assisted suicide law was passed via a ballot initiative in November 2008. During the election, that law was promoted as a right of individual people to make their own choices. That has not been our experience. We have also noticed a shift in the attitudes of doctors and nurses towards our typically elderly clients, to eliminate their choices.

Four days after the election, an adult child of one of our clients asked about getting the pills (to kill the father). It wasn't the father saying that he wanted to die.

Since the act passed, we have also noticed that some members of the medical profession are quick to bring out the morphine to begin comfort care without considering treatment. Sometimes they do this on their own without telling the client and/or the family member in charge of the client's care.

Since our law was passed, I have also observed that some medical professionals are quick to write off older people as having no quality of life whereas in years past, most of the professionals we dealt with found joy in caring for them. Our clients reciprocated that joy and respect.

Someday, we too will be old. I, personally, want to be cared for and have my choices respected. I, for one, am quite uncomfortable with these developments. Don't make our mistake.

Juan Carlos Benedetto

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Video: Margaret Dore vs. Wanda Morris Video, Part 1

To see Part 2 go here

CFI Okanagan Presentation
Should assisted suicide be legal in Canada?

Wanda Morris, Executive Director of Dying With Dignity vs.
Margaret Dore, President of Choice is an Illusion

Margaret Dore is President of Choice is an Illusion, a nonprofit corporation opposed to assisted suicide and euthanasia with a focus on the US and Canada. She is also a lawyer in Washington State where assisted suicide is legal. Her practice has included appeals, elder law, probate and guardianships. She is a former Law Clerk to the Washington State Supreme Court and has been licensed to practice since 1986. For more information, see www.choiceillusion.org andwww.margaretdore.com

Wanda Morris is the Executive Director of Dying with Dignity Canada, established in 1982 to educate the public about end of life options and the importance of advance care planning; to provide information and resources to the public and lawmakers about the choice in dying movement and the reasons why appropriately regulated medically assisted dying should be legalized in Canada; and to provide support for individuals at the end of their lives, including support at the bedside for those who wish to determine the nature and timing of their dying.

Video: Margaret Dore v. Wanda Morris Video, Part 2

To view Part 1, go here

Beware of Vultures: Senator Jennifer Fielder on Compassion & Choices

"I found myself wondering, 'Where does all the lobby money come from?' If it really is about a few terminally ill people who might seek help ending their suffering, why was more money spent on promoting assisted suicide than any other issue in Montana?"

By Senator Jennifer Fielder

As we wrangled through the budget this spring, the beautiful state capitol began to feel like a big, ripe carcass with a dark cloud of vultures circling about.  

Senator Jennifer Fielder

The magnitude of money in government attracts far more folks who want to be on the receiving end than it does those who just want fair and functional government. Until that ratio improves, it may be impossible to rein in unnecessary regulation and spending. 

Special interest groups spent over $6 million dollars on lobbyists to pressure Montana legislators during the 2013 session. Seems like a lot of money, until you compare it to the billions of taxpayer dollars at stake. Does the average taxpayer stand a chance against organized forces like that?


As your Senator one of my main duties is to sort out who wants your money, or a change in a law, and why. Getting to the bottom of it takes work. It would certainly help if well-intentioned citizens would do a little more research before clamoring onto any particular bandwagons as well.

We have to be careful not to be fooled by catchy slogans, shallow campaign propaganda, biased media reports, or plays on our emotions which, too often, conceal a multitude of hidden agendas. 

For example, it seems odd that the top lobby spender in Montana this year was Compassion and Choices, a “nonprofit” group that spent $160,356 advocating for legalization of assisted suicide. The second biggest spender was MEA-MFT, the teachers and public employees union who spent $120,319 pushing for state budget increases.

I earned a reputation for asking a lot of questions. I certainly didn’t take this job to rubber stamp anything. It's my duty to determine whether a proposal relates to an essential, necessary service of fair and functional government, or if it is motivated by piles of money to be gained from ill-advised government decisions.

You see, there is so much money in government that almost everything in government is about the money. The usual tactic is to disguise a ploy as “the humane thing to do”. . . . 

Some groups work very hard to provide factual information about their issue. Others stoop to the lowest of lows to invoke heart wrenching emotions, twisted half-truths, or outright lies. You really have to look carefully for all the angles.

Assisted suicide is another issue that can be highly emotional. There are deep and valid concerns on both sides of this life and death debate. But I found myself wondering, “Where does all the lobby money come from?” If it really is about a few terminally ill people who might seek help ending their suffering, why was more money spent on promoting assisted suicide than any other issue in Montana?

Could it be that convincing an ill person to end his or her life early will help health insurance companies save a bundle on what would have been ongoing medical treatment? How much would the government gain if it stopped paying social security, Medicare, or Medicaid on thousands of people a few months early? How much financial relief would pension systems see? Why was the proposed law to legalize assisted suicide [SB 220] written so loosely? Would vulnerable old people be encouraged to end their lives unnecessarily early by those seeking financial gain? 

When considering the financial aspects of assisted suicide, it is clear that millions, maybe billions of dollars, are intertwined with the issue being marketed as “Compassion and Choices”. Beware.

Public issues are not easy, and they are not always about money. But often times they are. If we want fair and functional government, we need to look deeper than most people are willing to look.. . .

* * *
Published as Communication from Your State Senator, "Beware of Vultures," by Montana State Senator Jennifer Fielder, Sanders County Ledger, http://www.scledger.net, page 2, 6-4-13. Senator Fielder lives in Thompson Falls MT, representing Montana State Senate District 7.

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Euthanasia: Where there's a Will, there's relatives

http://www.stuff.co.nz/stuff-nation/assignments/your-stance-on-euthanasia/9299105/Euthanasia-Where-theres-a-Will-theres-relatives

By Dee Burton (excerpt)

I liken the death experience to birth when talking to the elderly people I work with - it can be so hard to go through, yet is inevitable.

None can know for absolute sure what, if anything, lies on the other side. Euthanasia promoters make some assumptions about 'nothing' or 'peace', Christians talk of hell for those who have rejected a loving God who lives in heaven.

My biggest concern however is something we do know about - relatives who are keen to get their hands on what is left behind. We've all seen and heard of the acrimony and greed of relatives and lawyers and the pressure they can put on the execution of the Will.

My fear is that legalising of euthanasia will have that pressure put on the dying relatives, and it is so obvious that this will occur.

"I was afraid to leave my husband alone"

When my husband was seriously ill several years ago, I collapsed in a half-exhausted heap in a chair once I got him into the doctor's office, relieved that we were going to get badly needed help (or so I thought).

To my surprise and horror, during the exam I overheard the doctor giving my husband a sales pitch for assisted suicide. 'Think of what it will spare your wife, we need to think of her' he said, as a clincher.

Now, if the doctor had wanted to say 'I don't see any way I can help you, knowing what I know, and having the skills I have' that would have been one thing. If he'd wanted to opine that certain treatments weren't worth it as far as he could see, that would be one thing. But he was tempting my husband to commit suicide. And that is something different.

I was indignant that the doctor was not only trying to decide what was best for David, but also what was supposedly best for me (without even consulting me, no less).

We got a different doctor, and David lived another five years or so. But after that nightmare in the first doctor's office, and encounters with a 'death with dignity' inclined nurse, I was afraid to leave my husband alone again with doctors and nurses, for fear they'd morph from care providers to enemies, with no one around to stop them.

It's not a good thing, wondering who you can trust in a hospital or clinic. I hope you are spared this in Hawaii.

Kathryn Judson, Oregon 
Published in the Hawaii Free Press, February 15, 2011.
To view as published, click here and scroll down towards the bottom of the page.   

"But Doctor, I Want To Live": The Other Side Of The "Dignified Death" Debate

http://www.forbes.com/sites/davidshaywitz/2013/12/18/but-doctor-i-want-to-live-the-other-side-of-the-dignified-death-debate/

The emerging narrative about “Do Not Resuscitate” (DNR) orders is that they are not utilized frequently enough.

Doctors, it is said, are reluctant to have this discussion with patients, and patients are typically unlikely to

David Shaywitz, MD

initiate such a conversation with their physician.  As a result, there are dreadful stories of dying patients who suffer excruciating, highly-medicalized deaths rather than one with the dignity the sufferers might have preferred.  Such deaths, policy experts note, would also seem to constitute a regrettable waste of healthcare resources.

This is a powerful storyline because in many cases, it’s unfortunately true.  Many patients have experienced precisely the sort of end-of-life care they never would have wanted.  In some cases, these patients never formally codified their wishes, in other instances, patient wishes were tragically, at times incomprehensibly disregarded by the healthcare system.

Many have also complained (I’m one of them) that an ACA provision that would have allowed Medicare reimbursement for a proactive doctor-patient conversation about end-of-life care was withdrawn due to the misguided uproar ignited by some vocal critics.

But there’s another perspective as well, one highlighted by a recent experience I just learned about, involving the mother of a friend.

The patient in question is a 97 year old crusty Italian lady who had been living on her own, in generally good health, for a long time.  A month or so ago, her primary care doctor diagnosed her with anemia, and transfused her but didn’t initiate a workup, apparently assuming it wouldn’t be indicated in a patient of this age.  Shortly thereafter, the elderly woman presented to the emergency room with more severe anemia, and evidence of a GI bleed.

The woman was stabilized with transfusions, and as usual, entirely lucid.  The doctors told her they assumed she wouldn’t want a workup or any interventions, and would prefer to be made comfortable.
No, she said, I’m OK with interventions.

Then, the topic of DNR:  interventions might be dangerous in a patient of her age, the doctors told her.  If an intervention occurs, and something goes wrong, we assume you wouldn’t want extraordinary measures?

No, that would be OK too, she told them.

Really? You realize how violent and painful these might be, they asked, employing the same scare tactics I remember from my medicine residency, when overworked surgical consultants would occasionally try to talk a patient out of getting a procedure like a sinus tap.

That’s OK, she said.  I want to live.

In the end, the woman was scoped and discovered to have an easily-treated lesion (an arterial-venous malformation), which was quickly cauterized.  The woman tolerated the procedure well, is recovering nicely, and is slated to return home shortly.

This story deeply resonated with me, evoking my own experience with my Uncle Marvin  – see here and here. It also doesn’t strike me as all that unusual or exceptional, and highlights with unusual clarity the potential hazards of the push towards DNRs.

The big concern is that virtuous physicians – perhaps intending to do good for the patient,  perhaps (in the context of “parsimony”) intending to conserve societal resources and do good for the world at large – will undervalue a patient’s will to live or right to live.

Unfortunately, it’s probably not all that uncommon for a doctor to pressure a patient into making a decision the doctor earnestly believes is best; some would say it happens every day.

Both my uncle and the elderly lady profiled above were able to resist unreasonable physician pressure and successfully exert their autonomy.  What about the many other patients who are persuaded –bullied? — by their doctor into declining treatments they might actually desire?

I appreciate the importance and virtue of proactive DNR conversations between patient and doctor, and recognize the good that can, should, and must emerge from these essential conversations.

What worries me, however, is the righteousness driving some of the doctors who are leading these discussions – a deep-seated conviction that they’re better positioned than patients to know what’s the right choice for patients, and perhaps even “ethically” obliged to guide patients in this direction.

It’s arrogance masquerading as virtue, and endangers patient autonomy.