Think Tank

Should Terminally Ill Californians Have the Right To Choose How, When They Die?

Five states allow terminally ill patients the right to ask for medical help to plan their own deaths. California may become the sixth.

A bill in the Legislature would allow physicians to prescribe medications to give dying patients some control over when and how they die.

California lawmakers have tried and failed several times to get various versions of death-with-dignity bills signed into law. Proponents say if this attempt in the Legislature fails, they’ll try to get the issue before voters with a statewide ballot initiative.

The End of Life Options Act — SB 128, by state Sens. Lois Wolk (D-Davis) and William Monning (D-Carmel) — would make California the sixth state to approve right-to-die laws, following in the footsteps of Oregon, Montana, New Mexico, Vermont and Washington. Three states — Connecticut, Massachusetts and New Jersey — have rejected similar legislation. State legislation is being proposed this year in several states in the wake of the much-publicized case of Californian Brittany Maynard, who moved to Oregon to take advantage of Oregon’s right-to-die law. Maynard, who had an inoperable brain tumor, died in Oregon in November last year, using a lethal dose of barbiturates prescribed by her doctor.

We asked legislators, physicians, consumer advocates and scholars whether California should give terminally ill patients the right to choose how, when and where they die.

We received responses from:

CMA Stance Has Been Consistent, Clear

The California Medical Association has had extensive discussions around the issue of physician-assisted suicide, and as recently introduced legislation once again brings the subject center stage, that conversation will continue among our physician members in the Council on Ethical Affairs and at our Council on Legislation meeting.

While our organization, representing more than 40,000 physicians statewide hasn’t taken a position on Senate Bill 128 itself, our historical stance on the topic has been clear.

Longstanding CMA policy, which has been debated numerous times in recent years, is opposed to physician-assisted suicide because it is fundamentally incompatible with the physician’s role as a healer, creates an inherent conflict of interest in the physician-patient relationship and defies physicians’ commitment to the use of comfort care measures that can alleviate the physical and emotional suffering that dying patients experience.

In 1987, CMA adopted policy opposing enactment of any law which would require a physician to provide the medicines, techniques, advice or referrals necessary for a patient to pursue a course of suicide. As a follow-up to those actions, CMA adopted policy in the 1990s that while physicians may diagnose a patient as having a terminal condition or illness and may find a patient competent to make informed decisions, CMA condemns voluntary active euthanasia by physicians as unethical and unacceptable and opposes physician-assisted suicide clinics, yet remains receptive to the multiple views and perspectives expressed by various participants in the social dialogue on physician-assisted suicide. Again in 2001, the issue came up and CMA endorsed the concept that palliative care should be offered as the treatment of choice for those who are in a permanently vegetative state and supports the principle that patients have the right to refuse specific procedures and tests. In 2008, CMA adopted policy to continue to study the ethical and legal issues involved in physician assisted suicide and most recently in 2009, 2010 and 2013, CMA’s House of Delegates debated but rejected proposals to take a neutral position on physician-assisted suicide.

CMA physicians recognize the need for — and have been actively advocating for — appropriate end-of-life care through education and legislative efforts. Ensuring patients and their families have the information and care they need, especially in cases of fatal illness, remains a top priority for our organization. 

Patients Deserve Control

The choices we make about how we approach the end of our lives arise from our personal experiences, opinions and convictions, both faith-based and philosophical. Whenever there is legislation proposed around the issue, people on both sides argue passionately from those perspectives. The passion comes precisely from how deeply personal our decisions are about these matters, and how protective we are of our right to make those choices for ourselves.

When faced with the end of life, whether we choose to undergo or decline life-extending treatment and what we tell our loved ones to do should we end up on life support, we all agree that those choices should be respected and the right to make them defended.

Our bill, SB 128, will add one more option for terminally ill patients who feel that they wish to exercise, as a last resort, the choice of when and how they die and how much suffering they are able to tolerate.   

Our proposal would allow a person with a terminal diagnosis to request medication to bring about a peaceful death. It includes restrictions and oversight to ensure that no one will request the medication or take it under anything other than their own will. It also explicitly allows for health care providers to opt-out of participation, with reasons of “conscience, morality or ethics” all respected in the law.

A recent poll conducted by Medscape shows for the first time that the majority of doctors in America are in favor of allowing for the choice of aid in dying. It is a choice that a majority of Californians, across all demographics, now also support. It is a choice that Brittany Maynard, a 29-year-old California woman with an inoperable brain tumor, moved to Oregon to exercise. Maynard was an exception in that she had the resources to uproot her life in order to end it on her terms. No one else should have to do so.   

In trailing so many other states in the expansion of end-of-life care options, California now has years of evidence to refute the slippery slope arguments offered by the opposition: that people will be killed against their will, or that it will be used by people who do not have a terminal illness. The records in Oregon, Washington, New Mexico, Vermont and Montana clearly show that none of these threatened scenarios materialized. In fact, very few people have requested the drugs, and many of those have not taken them.

It’s important to remember that the people our bill will help are not choosing to die; instead, they are choosing how to live while they are dying. They are determining for themselves whether it will be a quick or prolonged process, and how much pain they will bear, while still in full control of their minds and bodies. They deserve control of the manner of their imminent, inevitable death from a terminal illness. If we don’t incorporate this into the meaning and practice of medical care, we abdicate our responsibility not only to those who suffer, but to those who may attempt to end their lives by alternate means.

Safeguards Against Abuse Not Strong Enough

In the past two decades, legalization of assisted suicide has been rejected more than seven times in California, primarily because of opposition from the medical community, disability rights advocates, faith-based communities and organizations representing ethnic minorities. Across the country, legalization efforts have been rejected more than 100 times.

Why does assisted suicide garner such broad-based, bipartisan opposition? Individuals from across the political spectrum can recognize that once suicide becomes an acceptable option, all the supposed safeguards surrounding it are inevitably arbitrary. A six-month diagnosis is only an estimate; why not a nine-month or twelve-month diagnosis? These restrictions will be eroded over time, as is the case in Europe, where in Belgium, a patient with “untreatable depression” was given assisted suicide and in the Netherlands, a woman committed suicide because she did not want to go to a nursing home.

There is a psychological component that is being ignored in this debate.  Simply requiring that a patient have mental capacity to express a suicidal wish is an insufficient safeguard against abuse, and puts vulnerable individuals at risk of abandonment or medical negligence. Research on suicide has repeatedly demonstrated that most suicidal thinking is driven by treatable psychiatric conditions, most frequently clinical depression or related disorders. Yet, in Oregon, less than 6% of patients who took the assisted suicide option were referred for psychiatric evaluation — a very troubling trend that reveals that mental health is being ignored in this debate, and important efforts aimed at suicide prevention are being undermined by laws like the one in Oregon.

It is noteworthy that the most common reason for electing assisted suicide in Oregon is not intolerable pain or suffering, but the wish to avoid being a burden on others. The medical profession, and society as a whole, has a duty to exercise solidarity with the sick and dying, communicating to them that it is a privilege to care for them in their final days: no patient should be made to feel like a burden.

Suicide is already an enormous public health problem in our society, and constitutes the second  leading cause of death among adolescents and young adults, and the 11th leading cause of death overall in the United States. The medical and psychiatric community has worked hard to get at-risk individuals the help they need. The social acceptance of physician-assisted suicide will undermine these efforts and place vulnerable individuals at risk.

Assisted Suicide is Bad Medicine for California

California should not legalize assisted suicide, which is what The End of Life Options Act (SB 128) euphemistically proposes. Assisted suicide is bad medicine for the state.

The Disability Rights Education & Defense Fund warns that the bill adopts so-called “model” legislation from Oregon. It poses significant risks to people with disabilities, elderly people and the general public:

  • Deadly mix: Costing $300, assisted suicide is a deadly mix with our profit-driven health care system. Barbara Wagner, diagnosed with lung cancer and prescribed a chemotherapy drug, received a letter from the Oregon Health Plan refusing to cover her chemotherapy. Instead, they would pay for her assisted suicide.
  • Abuse: Abuse of people with disabilities, and elder abuse, is rising. Where assisted suicide is legal, an heir or abusive caregiver may steer someone toward assisted suicide, witness the request, pick up the lethal dose, and even give the drug. With no witnesses required at the death, who would know?
  • Our quality of life devalued: Society often underrates people with disabilities’ quality of life.
  • Mistakes: Diagnoses of terminal illness are often wrong, leading people to give up treatment, losing good years of their lives.
  • Careless: No psychological evaluation is required. People with a history of depression and suicide attempts have received the lethal drugs.
  • Burden: Financial and emotional pressures can also make people choose death.
  • Unnecessary: Anyone dying in discomfort that is not otherwise relievable may legally, in all 50 states, receive palliative sedation, wherein the patient is sedated to the point at which the discomfort is relieved while the dying process takes place peacefully. This means that today there is already a legal solution to painful and uncomfortable deaths.
  • No true safeguards: The safeguards are hollow, with no enforcement or investigation authority.

Voters and elected officials grow very wary of assisted suicide laws when they learn the facts — as they have repeatedly in California. Recent bills were rejected in Massachusetts, New Hampshire and Connecticut, due to bipartisan, grassroots opposition by disability rights organizations, medical professionals and associations, palliative care specialists, hospice workers and faith-based organizations.

We empathized with Brittany Maynard and her family. But it is important to remember that for every case such as this, there are thousands more who could be significantly harmed if assisted suicide becomes legal in California.