Is Assisted Suicide a Constitutional Right?

That's the question Montana's State Supreme Court will take up on Wednesday. 

It stems from the case of Robert Baxter, a 76-year-old retired trucker who died of lymphocytic leukemia. Baxter, while still alive, sought the right to die, and took his battle to the Montana court system. A lower court ruled in his favor, on the very day he died. The State of Montana appealed the decision and it has now reached the state's Supreme Court. 

According to the New York Times:

"The legal foundation for both sides is a free-spirited, libertarian-tinctured State Constitution written in 1972 at the height of a privacy-rights movement that swept through this part of the West in the aftermath of the 1960s. Echoes of a righteous era are reflected in language about keeping government at bay and maintaining individual autonomy and dignity."

It seems now, not only is the right to die being advocated for from some of the more liberally minded states (Washington and Oregon), but now we're seeing a movement come out of a more conservative, individualistic state. 

And we're seeing some different arguments because of the unique nature of Montana. For one, since so many people live in near isolation, opponents worry that the sick will be pushed into the law out of a lack of access to proper healthcare. Montana also already has one of the highest suicide rates in the nation, and some worry about enacting such a law in an area that already has problems with suicide. 

On the flip side, proponents state the need for individualism and autonomy in decision making—the rights of the individual to direct his or her own fate. 

This will be interesting to watch. And if the court does approve the assisted suicide, it will be interesting to see what type of law they come up with, since this move has not stemmed from a carefully drawn out initiative, the way Washington's and Oregon's laws did. Will they essentially copy Oregon's law, like Washington state did, or will they do entirely their own thing, which seems more in the character of Montana. 

First Death with Dignity in WA

Yesterday, Washington state had its first death under our new death with dignity law. It was a 66-year-old woman with stage four pancreatic cancer.

Here is an article about the case from The Seattle Times.

Palliative Care Grand Rounds, Volume 1, Issue 3

Welcome to volume one, issue 3 of Palliative Care Grand Rounds!

Here you will find an overview of what's been happening in the cyberworld regarding palliative care, death, dying, end-of-life care, and all sorts of related topics for the past month. 

Entries in this series are rotating throughout palliative-care-oriented blogs and are hosted on the first Wednesday of each month. Next month's series will be hosted by Thaddeus Pope at Medical Futility on May 6th. 

There is a lot here, so if you want to read a bit at a time and come back later to read some more, that might be a good way to approach it. I do realize it looks overwhelming :)

That said, let's jump right in ... 

This month, a study was released in JAMA telling us that terminal cancer patients who are self-defined as religious are nearly three times as likely to seek life-sustaining measures near the end, and are also less likely to prepare for death—in terms of advance directives, living wills, healthcare advocates.

Also this month, Washington's Initiative 1000 went into law, legalizing physician assisted suicide. One stipulation of the law is that hospitals and individual practitioners can choose to opt out of the legislation. The has the potential to cause massive confusion. As a Washington-based nurse practitioner, risaden of Risa's Pieces, has an excellent post on his thoughts on this law, what he has encountered related to it, and how it compares to Oregon's law.  

Taking a harder look at the risks of skiing without a helmet, and the signs of serious head trauma in the wake of Natasha Richardson's death—a sad reminder that death by falling is the third most common cause of accidental death. 

60-Second Psych in Scientific American takes a look at whether the suicide of Nicholas Hughes, the son of Sylvia Plath and Ted Hughes, was due to hereditary causes. Children of mother's who kill themselves are more likely to commit suicide ... but is that correlation or genetics?

If the Rapture occurred, what would happen to your bank account? That's right, the Christian Rapture. Well, Mark Head thinks that in the event of the Rapture, in the midst of God's eternal glory, you will still be worrying about what is happening to your financials down on earth, So, for a $40 fee, he has a service that sets up an email that can be sent to your relatives with your bank account information. (And you can totally trust Mr. Head with your financial information.) "Christians on call" for the site log on to it to keep it going. If no one logs on for three days, it is assumed Rapture has taken place, and the emails are sent out. I guess you'd want to pick your most heathen-y relatives, just to ensure they're left behind to receive the email. How do you start that conversation?

This piece is a real doozy. How you go from normal life and a simple spinout in snowy conditions to freezing to death, or nearly freezing to death. And what it's like to freeze to death. Fascinating. Well-written. From Outside magazine online. 

A story about taking care of Sean, a former Fortune 500 company worker with early onset Alzheimer's, from the blog Confessions of a Young Looking Social Worker. 

A geropsychiatrist writes about two old goats—one figurative and one literal—both using the same meds to good purpose. Funny!

A touching piece that comes very close to my interests. A medical librarian writes about her mother-in-law's good death from cancer—thanks largely to the help of good hospice care—and the bittersweet satisfaction that brought the family. 

The blog Palliative Care Success discusses a NEJM article that shows high-spending regions of the country are more likely to recommend hospitalization for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. They were also three times as likely to admit this patient to intensive care, and 30% less likely to discuss palliative care with the patient and family. The post suggests Advanced Palliative Care Organizations (APCOs) can help reduce the number of people dying in hospitals and reduce the number of days patients spend at the hospital near the end, but APCOs are limited in how many physicians and other professionals they are drawing. 

The relationship between palliative care and the church, the spiritual role of palliative care ... but also the palliative care needed by a dying church (in this particular community) are all addressed in this beautiful blog entry written by a former pastor and Tampa-based hospice worker. 

Losing a laptop becomes an opportunity to explore advance directives as a metaphor for being prepared for the death of technology with backup and storage. 

Fran Johns, one of my favorite bloggers, has a beautiful piece on the therapeutic and restorative qualities of pulling Oxalis. Fran is part of the slow-blogging movement and does not update often, but when she does, it is always something amazing. Be sure to bookmark her site. 

At The Mom and Me Journals dot Net, Gail Rae writes about donating some of her mother's items to a garage sale. The need to de-clutter leads her to rid the place of her deceased mother's items as if they are just things, but one special piece, a tiara, needs an important home. 

Dethmama finds welcome relief from her work as a hospice nurse in the form of a new puppy named Olive. She has also posted a long-awaited sequel to a great story, Hospice Hitwoman and the C.Y.A., about a family who is anxious to see their loved on pass away, before the right time even. 

At the Pallimed blog, Dr. Drew Rosielle discusses a study that shows most people do not understand the actual details of resuscitation, and many would choose to not have chest compressions, shocks IVs through the groin, even though those are sometimes regular parts of resuscitation. Dr. Rosielle also has an excellent post on JAMA's series on palliative care of latinos. 

Pride and Prejudice and Zombies: Seth Grahame-Smith has reworked Jane Austen's Pride and Prejudice to include zombie battles. You can find a fantastic (in every sense of the word) excerpt here. 

If you want some death at the movies, check out Sunshine Cleaning, an irreverent and touching comedy about two sisters who open an industrial cleaning business—specifically cleaning up after dead people. The film stars Emily Blunt, Amy Adams, and Alan Arkin. 

Is it ethical for a wife to use a deceased spouse's sperm for artificial insemination? The Health Monitor at Radiography Schools takes up this issue and contrasts it with other sperm-donor controversies of late.

Is there such a thing as a style for your illness? Dana Jennings writes about getting a buzz cut to develop a tough, "Prison Break"-esque style for his prostate cancer treatent. For him, the haircut is a "visible bulwark against the tide of emasculating side effects caused by the treatment of prostate cancer."

Thanks to all who sent in suggestions! I'm sure there is even more out there I couldn't get to. And if you're interested, here's where you can find issues 1 and 2. 

Death with Dignity Specifics Adopted ... and Not Adopted

Another article on the difficulties of implementing Washington's new death with dignity law, again, it is specifically focused on who will be choosing to opt out of the law and who will be choosing to administer it. (Individual pharmacists, doctors, hospitals, etc., are allowed to choose under the legislation.)

It will be interesting to see how all of this plays out.

One example: if you read this article closely, you will note that, while the University of Washington has not decided to opt out of implementing the law, the director of palliative care consult services at the UW does not plan to prescribe any lethal medications to his patients for now. He will instead refer them to Compassion & Choices of Washington.

Contradictions like these are sure to run throughout the system. I just hope there isn't too much confusion. We all know how confusing the healthcare system already is.

When it rains, it pours ...

Another piece of good news from our current administration.

From The New York Times:

"WASHINGTON — The Obama administration moved on Friday to undo a last-minute Bush administration rule granting broad protections to health workers who refuse to take part in abortions or provide other health care that goes against their consciences."

The article references issues related to women's rights and reproductive choice, but as I blogged earlier this week, Barbara Coombs Lee has been very vocal in getting the word out that this law would also affect people's access to death with dignity.

Death with Dignity Specifics Adopted

Washington state has adopted the specific guidelines that it will use to implement its new death with dignity law. The Seattle PI has this article about the guidelines.

Unfortunately, the article is not super informative and is actually pretty vague and confusing. (I think it tries to cover too much in one piece instead of just focusing on the most recent developments.) But I'm going to link to it anyway since it's one of the first mainstream pieces written about death with dignity in our area in a while.

I'm hoping, as the deadline approaches, some better, more specific information will come out.

The Conscience Rule

Barbara Coombs Lee of Compassion & Choices has recently been blogging at Huffington Post about the "conscience" rule.

This law went into effect on January 19 it allows medical workers to refuse to participate in care that goes against their moral beliefs. Obviously, one of the areas this can and will affect is death with dignity. And we already know some facilities in Washington state have decided not to participate in the newly passed law.

Particularly troublesome for me would be any physicians who would refuse treatment but also would not tell patients that the option is available for them. The post by Barbara Coombs Lee says most physicians who object to a treatment would let a patient know about a treatment but some would not—no figures are given though.

Whatever side you come down on, it is an important issue that is getting lost in the midst of economic worries. Check out the blog or Google the topic—but Google "conscience rule HHS," or you won't get decent results.

Death with Dignity Deadline Approaches in Washington

According to The Seattle Times, medical organizations throughout Washington state are struggling with whether to participate in Washington's new Death with Dignity Act.

And whether they decide to participate, they are frantically working to prepare for the March 5 deadline to be ready for implementation. Caregivers must be able to handle questions on the law, be set to refer patients, give out prescriptions if they and their organization are choosing to do so, know their policy on mental-health evaluations, etc.

Oregon, the only other state to legalize death with dignity, ended up with approximately three years to implement their law due to all of the legal challenges brought against it, as this New England Journal of Medicine article pointed out. Since their state's law was taken to the U.S. Supreme Court, we're unlikely to end up in a similar situation.

Let's hope for some patience and cool heads during this transition. It's a tight, tight deadline for Washington state. Only four months to put into place a very complicated and very controversial law.

January Poll Says "No" to Assisted Suicide on Television

So, my polls are always completely unscientific, being that they're internet polls that simply take the opinion of people who visit my blog and chose to vote. 

I can tell who comments if the posts aren't anonymous, but I do not track who visits. I track numbers of visitors, but that's it. 

Nonetheless, I find it interesting to ask questions, and I like having at least one interactive element on my blog. 

I've never had such a one-sided poll result before this month! 

To the January question: "Should an assisted suicide be aired on television?" the resounding answer is "No." 

1 "Yes", 22 "No," and 2 "I Don't Know." And, I have no way to know this for sure, but I would guess that people who visit this blog are more likely to be interested in talking/reading about death than the average person. So, it seems people do not want to see PAS on TV. 

It makes me wish I remembered better how the country reacted when 60 Minutes aired an assisted suicide enacted by Dr. Kevorkian in 1998. 

Televised Assisted Suicide in the U.S.

In the comments below, Dethmama asks whether assisted suicide has ever been televised in the U.S., as they have just done in Britain.

This is by no means a comprehensive answer, but I was reminded of 60 Minutes' interview with Dr. Jack Kevorkian from 1998, during which they televised the euthanasia of a man with Lou Gehrig's disease. (It was an actual euthanasia; Dr. Kevorkian was responsible for the act of death.) 

The interview was what led to Kevorkian's imprisonment for second-degree murder. He served about nine years of a 10–25 year sentence. 

I can't find the actual clip of the first interview, but I found this clip from a follow-up interview that shows most of the original piece within it. However, CBS' site won't let me embed it, so you'll have to follow the link to view. 

There are some marked differences between the U.S. piece and the British piece:

*First, the U.S. piece is as much about Kevorkian as it is about assisted suicide. 

*Second, I'm really struck by how the British piece gives the dying man a voice. And I realize someone with advanced Lou Gehrig's disease cannot speak well ... but there are other things that could be done—talking more to family, photos of his past, stories, etc. 

*Third, the British piece showed us an assisted suicide done through legal channels, so we are well positioned to confront the issue. The shock value of breaking the law, doing things behind closed doors, with shady methodology, all of that is gone. Dr. Kevorkian lost his medical license in 1991. Thus, he didn't have access to the usual cocktail of barbituates used for assisted suicide. What we see in the U.S. piece are his makeshift means. In the British piece, the man's death feels peaceful; he says goodbye to his wife. I see a death with dignity. In the U.S. piece, I see a more haphazard way of ending suffering. 

Assisted Suicide in Britain

Controversy has flared up over assisted suicide in Britain this past week.

This catalyst was a televised assisted suicide—the suicide of Craig Ewert who was 59 and suffering from motor neuron disease.




Ewert took a fatal dose of barbiturates in a Zurich clinic in 2006, although the documentary covering his decision and final act was first shown just last week.

Assisted suicide is illegal in Britain. According to the NY Times, about 100 Britons have committed assisted suicide in the past decade or so—by traveling to Switzerland or other locations where assisted suicide is legal.

I'm really glad the show aired. You all know I support death with dignity and assisted suicide, but beyond that, even for people who are against this movement, discussions like this get us all thinking and talking about death. And the more it comes into the open, the less alien it becomes. And I hope, the less frightening it becomes.

Ewert's wife was quoted in the New York Times saying, “For Craig, my husband, allowing the cameras to film his last moments in Zurich was about facing the end honestly,” she wrote in The Independent, a British newspaper. “He was keen to have it shown because when death is hidden and private, people don’t face their fears about it.”

My thoughts exactly.

NEJM Piece on Death with Dignity

From the New England Journal of Medicine, a nice overview piece on the passage of the Death with Dignity Act in Washington state, how it compares to the law in Oregon, what the two laws have meant for palliative care, and what they might mean for the future of palliative care.

It's a lot to cover in such a short article, but Dr. Robert Steinbrook offers a succinct and logical take on the controversies and goings-on.

One interesting point: due to legal challenges, Oregon law makers and health workers had about three years to figure out how to implement their version of the law, while Washington state will only have four months. How will this change the shape of care?

Initiative 1000—Death with Dignity—Update

Officials in Olympia have begun drafting legislation for Washington state's new death with dignity law. According to The Seattle Times, they have four months to come up with the exact law ... because it goes into effect on March 4.

Ah, also, just found this. ... mynorthwest.com has an even better article with more information. Two points of note. The piece points out that any legal challenges to the law could be difficult since Oregon's law has been upheld by the Supreme Court. Also, it quotes Jennifer Hanscom, spokeswoman from the Washington State Medical Association, which opposed the initiative: "She said it will be looking closely at the initiative language to see if there's room for improvements, but 'we are not actively seeking any changes.'"

Both facts are good to hear, although I'll be surprised if implementation is not some sort of struggle, if for no other reason than Seattle and Washington state are famous for over-processing everything!

Death with Dignity Initiative Passes in Washington

The Seattle Times is projecting victory for Washington State's Death with Dignity Initiative, I-1000. I'm so grateful and proud of my home state. And score one for the initiative process!

This makes us only the second state in the country to pass such legislation.

If Oregon's history with the law is any indication, many legal battles are in the future for Washington's Death with Dignity legislation. But this is a big step forward. And any legal battle means more press, which means more discussion about the way we die.

A Necessary Death

The link for this video came from my friend Amelia.



It's a movie that poses as a documentary about suicide. Thankfully, not an actual documentary.

The filmmaker seeks to follow a person from the initial instinct of wanting to commit suicide to the day that they commit the act.

It's an interesting premise because, being a piece of fiction that pretends at nonfiction, it lets us explore the ethical issues that would be involved with such a documentary—why wouldn't the filmmaker stop the suicide? should suicide be entertainment? should the filmmaker try to help the suffering person?—without anyone actually being ethically complicit in the act.

And clearly from this YouTube clip, we can see they're advertising it as though it is a documentary. So, the film's producers want the confusion to exist.

I still have concerns that they're turning suicide into entertainment. Meta though the film may be, the act of suicide and the conversation around it become the main narrative thrust that push this movie forward. But it hasn't screened in Seattle yet, and I don't want to judge too harshly something I haven't seen. So, I'll keep an open mind until I've had a chance to view it.

Here's a link to the film's website.

"I'm not afraid of dying ... I'm just afraid of dying like this."

A quote from this piece in today's Seattle PI. The article covers some of what has happened over the 10 years Oregon's Death with Dignity law has been in place. I think it does a better job of providing a balanced overview than The Seattle Times piece did. (Less focus on exceptions, more compilation of overall statistics, although it's still a bit negative and fear-laden for my tastes.) The visual I include here is from the PI's article.

I hope this law passes. But right now, I'm so happy to see an article about the way we face death on the front page of Seattle's daily paper. This is definitely a step toward helping us all talk about death to the extent we should. Yay!

Also, I promise a thoughtful, non–I-1000 related post soon. It's just been in the news and on my mind a lot lately.

One Patient's Struggle with Death with Dignity

The Oregonian has this heart-wrenching site, which offers an amazing opportunity to see inside one woman's struggle with decisions related to Death with Dignity.

Lovelle Svart was a former employee of the paper diagnosed with stage IV lung cancer who had supported Death with Dignity in theory but now had to decide whether to actually apply it to herself.

I think anyone who is charged with the opportunity to vote on I-1000 in Washington state this November should see this as part of making an informed decision. And it would be illuminating for anyone. But I will warn you, it is not easy to watch, read, or listen to.

Here is a link to the general page. And here is a link to audio and video from Svart's last hours and minutes.

Death with Dignity in Oregon

The Seattle Times is running an article about Oregon's Death with Dignity law, focusing on some of the cases and trends that have come up over the roughly 10 years that it has been in effect. I wish the article focused more on the generalities and less on the exceptions, but nevertheless, it is an interesting read.

Dan Savage on I-1000

A very personal column in today's issue of The Stranger. Dan Savage writes about his support of I-1000, in light of his mother's recent death from polmonary fibrosis.

Here is a particularly Dan Savegey excerpt from the piece:

"If religious people believe assisted suicide is wrong, they have a right to say so. Same for gay marriage and abortion. They oppose them for religious reasons, but it's somehow not enough for them to deny those things to themselves. They have to rush into your intimate life and deny them to you, too—deny you control over your own reproductive organs, deny you the spouse of your choosing, condemn you to pain (or the terror of it) at the end of your life.

The proper response to religious opposition to choice or love or death can be reduced to a series of bumper stickers: Don't approve of abortion? Don't have one. Don't approve of gay marriage? Don't have one. Don't approve of physician-assisted suicide? For Christ's sake, don't have one. But don't tell me I can't have one—each one—because it offends your God.

Fuck your God."

Physician Assisted Suicide—Follow-Up

Some more information on Physician Assisted Suicide:

First, here is a link to an excellent resource on how to examine PAS through an ethical framework. It is the University of Washington's Bioethics website. I worked on the site back in 2002/2003. It is geared toward helping medical students learn to handle situations that will likely emerge once they become doctors, but I think the discussion can apply to anyone who is interested in picking apart this topic more fully. And it gives ethical arguments for BOTH SIDES.

Second, one question I have heard raised a lot on other blogs is why proponents of I-1000 don't just call what they are advocating for euthanasia. I'd like to explain that briefly. Euthanasia and PAS are two distinct terms. Euthanasia can be used to describe ending a life in a painless manner, a mercy killing if you will, but a euthanasia is actually performed by the medical personnel. In the case of PAS, a prescription is handed out by the doctor, and pills are given to the patient for the patient to take home and bring about death on their own. I'm not saying one is better than the other, just that there is a technical distinction.