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Death with dignity laws, also known as physician-assisted dying or aid-in-dying laws, stem from the basic idea that it is the terminally ill people, not government and its interference, politicians and their ideology, or religious leaders and their dogma, who should make their end-of-life decisions and determine how much pain and suffering they should endure.
Death with dignity statutes allow mentally competent adult state residents who have a terminal illness with a confirmed prognosis of having 6 or fewer months to live to voluntarily request and receive a prescription medication to hasten their inevitable, imminent death. By adding a voluntary option to the continuum of end-of-life care, these laws give patients dignity, control, and peace of mind during their final days with family and loved ones. The protections in the statutes ensure that patients remain the driving force in end-of-life care discussions.
Existing physician-assisted dying laws mirror Oregon’s Death with Dignity Act, which is widely acclaimed as successful and which independent studies prove has safeguards to protect patients and prevents misuse.
The death with dignity process is robust: Two physicians must confirm the patient’s residency, diagnosis, prognosis, mental competence, and voluntariness of the request. Two waiting periods, the first between the oral requests, the second between receiving and filling the prescription, are required.
Current Death with Dignity Laws
The following U.S. jurisdictions have death with dignity statutes:
- California (End of Life Option Act; approved in 2015, in effect from 2016)
- Colorado (End of Life Options Act; 2016)
- District of Columbia (D.C. Death with Dignity Act; 2016/2017)
- Hawaii (Our Care, Our Choice Act; 2018/2019)
- Maine (Death with Dignity Act; 2019)
- New Jersey (Aid in Dying for the Terminally Ill Act; 2019)
- New Mexico (Elizabeth Whitefield End of Life Options Act; 2021)
- Oregon (Death with Dignity Act; 1994/1997)
- Vermont (Patient Choice and Control at the End of Life Act; 2013)
- Washington (Death with Dignity Act; 2008)
Visit our State Statute Navigator where you can not only research every currently enacted law, but also download a complete manual of the laws and our model language recommendation for new bills. Easily access state data reports using our State Report Navigator.
Montana does not currently have a statute safeguarding physician-assisted death. In 2009, Montana’s Supreme Court ruled nothing in the state law prohibited a physician from honoring a terminally ill, mentally competent patient’s request by prescribing medication to hasten the patient’s death. Since the ruling, several bills have been introduced to codify or ban the practice, none of which have passed.
Exit in the British Medical Journal
How to Die With Dignity was the world’s first rational suicide manual for persons suffering from unbearable and unrelievable illness. This month, the BMJ, one of the world’s leading medical journals, publishes details of Exit’s work and history. It was … Continue reading →
The ironies of 50 yrs – being allowed vs being able
Several writers were hanging out the flags yesterday. Fifty years ago, the Suicide Act was changed to make suicide legal and keep assisted suicide illegal. From August 1961 you were ‘allowed’ to take your own life without facing criminal charges … Continue reading →
Raising the flag against suffering
Ancient legend places the history of the Scottish Flag – and the Scottish ‘National Anthem’ – as a symbol of triumph over insuperable odds, of hope for the future. The Flower of Scotland anthem commemorates self-determination in days that are, … Continue reading →
Enabling choice at the end of life
photo credit: NMIH
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Five Last Acts 2nd Edition (Click image to order). Helium, Drugs, Compression Technique, Plastic Bags, Starvation-Dehydration examined & explained. The authoritative guide.
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Distinguished Professor of Philosophy and Director: Centre for Applied Ethics, Stellenbosch University
Anton van Niekerk is director of the Centre for Applied Ethics and Head of the Unit for Bioethics in that Centre. The Unit receives an annual contribution from Mediclinic, but that is not for the exclusive use of Anton van Niekerk.
Stellenbosch University provides funding as a partner of The Conversation AFRICA.
Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.
Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time.
Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in an article in the Washington Post. He wrote:
I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.
Assisted death can take the form of physician assisted suicide (PAS). Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life.
The latter procedure is also referred to as “voluntary active euthanasia” (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.
Passive form of euthanasia
The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted.
However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.
There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.
Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.
Death with dignity
In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.
Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering.
Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.
I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.
Argument in favour of assisted suicide
The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy.
We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence. The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right.
It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.
Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.
My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy.
Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go.
The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.
“It’s not something I tell everyone,” the 46-year-old from Port Elizabeth says. “But under certain circumstances I feel one should have the right to make this choice.”
Carol’s story recently came to light in the documentary movie Define: Living, made by students at the Afda film school in Johannesburg.
This mom of two was diagnosed with colon cancer nine years ago and the cancer has since spread to her liver and other parts of her body. Carol, formerly a personal assistant at a law firm, had to stop working last year.
In the documentary she describes how hard it was for her to hear that her cancer is terminal.
“My son recently told me, ‘You know the time we really knew was when you lost your hair,’ ” she says.
A first her partner struggled to comprehend when Carol told him her cancer had spread. “I asked him if he understands what I’m telling him. He said, ‘Yes, it has something to do with the cancer.’ That’s when I had to explain to him, ‘I’m terminal.’ He went white as a sheet.”
Carol says her parents in particular are having trouble coming to terms with the fact she wants to decide when to die.
“They don’t want me to suffer. They know that I’m a reasonably intelligent person and they’ll support my decision,” she says.
“It won’t be easy. But if they’re given the choice to see me suffer, in pain… And it’s about pain – a lot of it – but it’s also about dignity, because you get pain killers. It’s about the loss of dignity. The loss of me. And if they’re given these options they would happily support me.”
She says more than the pain, the loss of dignity is what bothers her. She doesn’t want to be bedridden, unable to care for herself or control herself. “That’s not the way I want to go.”
Assisted dying is still illegal in South Africa and Carol says she’s afraid proposed new laws won’t be passed in time to help her.
“Because for me that leaves us in a situation of pure hopelessness. Then my choices become very limited. Then I can continue my treatment and I waste away and become not me. Lying in a bed in agony. Not being able to take care of myself and all the horrible things it entails. Or ending it myself.”
But she doesn’t see suicide as a real option, since there’s no guarantee it will work. She also doesn’t want to have her children to deal with a failed suicide attempt or to have to clean up after her. She wants there to be “a way for me to end this which is certain, and calm and dignified”.
“I don’t want to die,” she says with conviction. “I’m already dying, but I just want to have the choice as to how and when I’m going to die.”
Carol’s plight regarding assisted death in South Africa is by no means the only one. Advocate Robin Stransham-Ford won a court case in April last year in which the court found any doctor who’d help him die wouldn’t be prosecuted. Sadly, he died mere hours before the court delivered its verdict.
The national health department appealed the case, which will be heard in the Supreme Court of Appeal in Bloemfontein in November.