Physician-Assisted Death: Where It’s Legal and How It Works

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For many people with a terminal illness, dying can be a long and also painful process, both physically and emotionally. Some individuals will find that their suffering has significantly diminished their quality of life. In certain states, these people can have a say in when they will die by voluntarily requesting a life-ending prescription from their physician. The practice is typically referred to as physician-assisted death, aid in dying, physician-hastened death, or medical aid in dying. (You might still see the term physician-assisted suicide, though many advocates and medical organizations like the American Public Health Association shy away from it, explaining that a “suicide” usually ends a life that would have gone on.)

“The minority of patients who become seriously interested in this practice feel like they’re losing their dignity and personhood as they battle a fatal disease,” says Timothy Quill, MD, founding director of the Palliative Care Program at the University of Rochester Medical Center. “For them, it’s not about ending an otherwise open life, but about dying in a way that’s humane and more under their control with the intent of preserving their remaining personhood.”

While physician-assisted death can be a taboo topic for many families and is still debated amongst medical professionals and lawmakers, there’s a growing movement to understand how it works and why someone might choose it. Here’s what you need to know:

1. Physician-assisted death is not legal everywhere

In the United States, only California, Colorado, Vermont, Oregon, Washington, and the District of Columbia have regulations—often called Death with Dignity laws—that outline a protocol for how and when terminally ill people can end their life. (Montana does not have a specific Death with Dignity law, but the Montana Supreme court has ruled that aid in dying is legal in the state.) In April 2018, Hawaii became the seventh jurisdiction to enact such a law; it goes into effect on January 1, 2019. The laws do not require all physicians practicing in those states to take part in the process.  

These laws also make it possible for people interested in physician-assisted death to move to one of these states in order to go through the process, but it’s not a quick route. “Certain states require you to live there for at least six months before you can become a resident and most people who are considering physician-assisted death don’t have that much time,” Quill says.

2. Not everyone qualifies for physician-assisted death

One of the misconceptions about aid in dying is that you can march right into any doctor’s office and walk out with a prescription—but that’s not the case. “It’s a very thorough process with strict rules, and the patient goes through physical and psychological evaluations to make sure they qualify,” explains Quill.  

To be considered, two physicians must sign off on a few conditions: the person is at least 18, is mentally competent, has been diagnosed with a terminal illness that will lead to death within the next six months, and is able to self-administer and ingest the medication. If the person doesn’t meet even one of these conditions, they aren’t eligible.

3. Physician-assisted death is a multi-step process

Before a consenting doctor can write a prescription for a life-ending medication, there are a few steps that both the doctor and terminally ill person need to take. First, the person has to make an initial oral request to their doctor, who must be licensed in that state. The doctor—also referred to as the attending physician—then confirms that the person meets the requirements and also discusses other options such as increasing pain management medications or making changes to hospice or palliative care.

Mental health issues such as depression would disqualify a person from being able to move forward with physician assisted death, so during the initial assessment, the physician will also screen for them and refer the patient to a psychiatrist or psychologist if need be. If the attending physician gives the green light, a second, consulting doctor has to verify the person’s eligibility as well.

After the first oral request, the patient can start filling out their state’s required paperwork, which two witnesses have to sign. Then the patient makes a second oral request to the attending physician, at least 15 days later. In some states, like Vermont, the doctor has to wait another 48 hours after the second request before he or she can write the prescription, but in Colorado and California, they’re able to write the prescription immediately. The doctor can then dispense the medication, which is typically a large dose of a sleeping medication like a barbiturate. There’s no deadline to fill or use the prescription.

4. Physician-assisted death is not euthanasia

Physician-assisted death and euthanasia are often thought to be the same practice, but there are a few differences between them. While physician-assisted death is legal in some states, euthanasia is illegal in the U.S., and many states that allow aid in dying have specific language that prohibits it. The two terms also differ in terms of how much responsibility the patient has during the process. During euthanasia, a doctor gives the patient a lethal dose of a medication—usually by injection—in order to prompt death. But for physician-assisted death, one of the key criteria is that the patient must be able to administer and ingest the medication themselves, which holds them accountable for their decision.   

5. Physician-assisted death is still controversial in the U.S.

Though countries like Canada have made aid in dying legal on a national scale, in the U.S., it’s still up to each state to decide whether it’s lawful. Though physician-assisted death might contradict some people’s moral standing on death—should a person have the power to end their own life?—there’s also debate on the medical side of it. “When you take the Hippocratic Oath as a physician, you promise that you will ‘do no harm.’ Many people question whether physician-assisted death violates that promise and if by encouraging the process, a physician is upholding his or her responsibility to heal people,” says Quill.

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