Analysis Iowa Doctor-Prescribed Suicide Bill (2015)

House File 65

This 2015 bill is the 2nd attempt by doctor-prescribed suicide activists to transform a prescription for a lethal dose of drugs into a “medical treatment.”  It is patterned after Oregon’s “Death with Dignity Act.”  This latest attempt comes at a time when suicide numbers are climbing in Iowa.[1]

Under the “Iowa Death with Dignity Act” (House File 65):

Doctor-prescribed suicide would become a “medical treatment.”

This would cause emotional and financial pressure on patients by giving insurance programs the opportunity to cut costs by denying payment of more expensive treatments while approving payment for the less costly prescription for a lethal drug overdose.

This has already been documented in Oregon – the state with the law upon which the Iowa bill is based.  The Oregon Health Plan (OHP) has notified some patients that medications prescribed to extend their lives or improve their comfort level would not be covered, but that the OHP would pay for a lethal drug prescription.[2]

Referring to payment for assisted suicide, the Oregon Department of Human Services explains, “Individual insurers determine whether the procedure is covered under their policies, just as they do any other medical procedure.”[3]

If the Iowa bill is approved, will health insurance programs do the right thing – or the cheap thing?

An individual with a controllable medical condition could be considered to have a terminal disease, making him or her eligible for doctor-prescribed suicide.

To be eligible for a suicide prescription, a patient is considered to have a terminal disease if the condition is “incurable and irreversible disease” and “will, within reasonable medical judgment, produce death within 6 months.”[4]

There are many conditions (diabetes, certain types of leukemia, disabilities requiring ventilator support, etc.) that, without medical treatment, would result in death within six months.  However, with medical treatment, individuals with those conditions could live for many years.  Yet those individuals would be eligible for doctor-prescribed suicide.

There is documentation that this has occurred under Oregon’s assisted-suicide law.  In the latest official report from Oregon, diabetes is noted as the underlying terminal condition that made the patient eligible for a lethal prescription.[5]

Why is the definition of “terminal disease” so broad?

Severely depressed or mentally ill patients could receive doctor-prescribed suicide, without having any form of counseling or mental evaluation. 

Even if the patient is severely depressed or has a mental illness, a physician is not required to refer the patient for counseling unless the physician believes that “the patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment.”[6]  As long as the patient can make and communicate decisions and understands what he or she is requesting, no counseling is required.

This provision is similar to that contained in Oregon’s law where, in 2014, only 3 of the 155 patients who received lethal prescriptions were referred for a psychological evaluation.[7]  A study about Oregon’s law found that it “may not adequately protect all mentally ill patients.”[8]

“Doctor shopping” could take place until a health care professional can be found to declare that the patient is qualified for the lethal prescription.

If a patient is found to have “impaired judgment,” the bill does not prohibit a health provider, family member or another person from arranging for the patient to be evaluated by other counselors until one is found who would declare the patient capable of choosing assisted suicide.

This has taken place in Oregon where it has been noted that “a psychological disorder — senility, for example — does not necessarily disqualify a person.”[9]

A woman died of assisted suicide under Oregon’s “Death with Dignity Act,” even though she was suffering from early dementia. Her own physician had declined to provide a lethal prescription for her. When counseling to determine her capacity was sought, a psychiatrist determined that she was not eligible for assisted suicide since she was not explicitly pushing for it and her daughter seemed to be coaching her to do so. She was then taken to a psychologist who determined that she was competent but possibly under the influence of her daughter who was “somewhat coercive.”

Finally, she was assessed by a managed care ethicist who determined that she qualified for assisted suicide, and the lethal dose was prescribed.[10]

A person “familiar with the patient’s manner of communicating” could inaccurately convey (translate) the patient’s requests for the lethal dose.

Under the bill, patients are considered capable of requesting doctor-prescribed suicide not only by communicating the decision on their own but also by “communication through persons familiar with the patient’s manner of communicating if those persons are available.”[11]

This could lead to a patient’s wishes being misunderstood, misinterpreted, or disregarded.  There is no requirement that such communication assistance be independently verified.

How would anyone know if the translation is accurate?

The required requests could be made by telephone and the written request electronically transmitted or delivered to a physician by a third party. 

The individual is required to make two oral requests and one written request for doctor-prescribed suicide.[12] However, there is no requirement that any of the requests be made in the presence of the attending physician.

Additionally, the bill states that, if unable to orally communicate, a patient may make a valid oral request by reducing the oral request to writing for submission to the physician.[13]

Family members or health care providers and others could advise, suggest, encourage or exert subtle and not so subtle pressure on vulnerable individuals to request doctor-prescribed suicide.  

The bill states that witnesses to the written request must attest to the fact the patient is “acting voluntarily, and is not being coerced to sign the request”.[14]  However, those words have a narrow legal meaning.  The bill does not prohibit someone from suggesting, advising, or encouraging a patient to request doctor-prescribed suicide.

Since victims of domestic abuse, including elder abuse, are extremely vulnerable to persuasion from their abusers, it takes little imagination to understand how the bill could put abused individuals at risk of being persuaded to request doctor-prescribed suicide.

The written request for doctor-prescribed suicide could be witnessed by someone who would gain financially from the patient’s death.

The written request, which could be signed in the patient’s residence, must be witnessed by two individuals, only one of whom may not be someone who would be entitled to any portion of the patient’s estate.[15]  Thus, one witness may be a potential heir who is encouraging or pressuring the patient to sign the request.  The second witness could be the “best friend” of the potential heir.

This places victims of elder abuse and domestic abuse in great danger since they are unlikely to share their fears with outsiders or to reveal that they are being pressured by family members to “choose” doctor-prescribed suicide.[16]

The bill permits a person who would benefit financially from the person’s death to pick up and deliver the lethal prescription.

The drugs can be dispensed to “an expressly identified agent of the patient.”[17]  A potential heir could encourage the patient to authorize him or her to pick up the drugs for delivery to the patient’s residence.

Individuals could request doctor-prescribed suicide based on fear of being a burden to others.   

In the last official Oregon report, fear of becoming a burden on others was given as a reason for requesting lethal drugs by 40% of those who died using that state’s assisted-suicide law.[18]

A health care facility could not prevent deaths from doctor-prescribed suicide on its premises. 

The bill states that “a health care provider may prohibit another health care provider from acting under this chapter on the premises” if certain notification is provided.  Additionally, it states that a health care provider cannot be prevented “from providing health care services to a patient that do not constitute action under this chapter” [19]

However, the phrase “action under this chapter” is very narrowly defined in the bill.[20]  It refers only to performing the duties of the attending physician, the consulting physician or one who would be carrying out the counseling, if performed.  It does not include nurses, pharmacists and other individuals.

Therefore, facilities would not be able to prevent others from bringing a lethal drug prescription to a patient or resident to self-administer on the premises; would not be able to prevent the witnessing of the written requests for doctor-prescribed suicide; would not be able to prohibit a pharmacy on the premises from dispensing the drugs; and would not be able to prevent nurses or other health care providers from bringing the lethal drugs to a patient or resident.

Patients would have no protection once the assisted-suicide prescription is filled. 

Like the Oregon law, the bill only addresses activities taking place up until the prescription is filled.  There are no provisions to insure that the patient is competent at the time the lethal drug overdose is taken or that he or she knowingly and willingly took the drugs.

Due to this lack of protection, the bill would put patients at enormous risk.  For example, someone who would benefit from the individual’s death could trick or even force the person into taking the fatal drugs, and no one would know.

Why are there no safeguards at the most important part of the process – at the time the patient takes the drugs that will cause death?

There is an illusion of choice.  Yet, the bill would actually constrict patient choice.

“Choice” is an appealing word, but inequity in health care is a harsh reality.

Under the bill, before writing a prescription for death, a doctor must inform the patient of “the feasible alternatives, including but not limited to comfort care, hospice care and pain control.”[21]  However, “informing” someone of all options does not mean the patient will have the ability to access those options.  It only means the person must be told about them.

Patients may find that their insurance will not cover the “feasible alternatives” their doctors informed them about but, instead, will pay for doctor-prescribed suicide as has already happened in Oregon.[22]

If doctor-prescribed suicide becomes just another treatment option, and a cheap option at that, the standard of care and provision of health care changes.  There will be less and less focus on extending life and eliminating pain, and more and more focus on the “efficient and inexpensive treatment option” of death.

If doctor-prescribed suicide is legalized in Iowa, it could become the only “medical treatment” to which many people have equal access.  The last to receive health care could be the first to receive doctor-prescribed suicide.
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Note:  Supporters of HF 65 point to Oregon in their claim that there are no problems with the law and that safeguards contained in the law are meticulously followed and monitored.  Yet, in closed-door sessions, those supporters acknowledge that this is not true.  For documented information about this contradiction, see “The Oregon Experience.”[23]
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[1] There were 445 suicide deaths in Iowa in 2013, according to information released by the Iowa Department of Public Health in December 2014. That number was a 17 percent increase from the previous year.
“Suicide numbers climb in Iowa, data show,” Des Moines Register, January 28, 2015.  Available at: http://www.desmoinesregister.com/story/news/2015/01/28/suicide-numbers-climb-iowa-data-show/22484489 (last accessed 4/21/15).

[2]  KATU Television, “Letter noting assisted suicide raises questions” (interview about one such case and the response of the Oregon Health Plan). Available at:  http://www.katu.com/news/26119539.html  (last accessed 1/29/15).

[3]  Oregon Dept. of Human Services, “FAQs about the Death with Dignity Act.”  Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/faqs. aspx (last accessed 12/30/14).

[4]  Section 142.E.2 (16).

[5]  Official report for 2014 deaths under Oregon’s Death with Dignity Act, p. 6, fn. 6.  Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/ year17.pdf (last accessed 4/6/15).

[6]  Section 142.E.2 (5); Section 142.E.6 (1) (e);  and Section 142.E.8 (1).

[7] Official report for 2014 deaths under Oregon’s Death with Dignity Act, p. 5.  Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf (last accessed 4/6/15).

[8] Linda Ganzini, Elizabeth R. Goy, Steven K. Dobscha, “Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey,” British Medical Journal, Oct. 25, 2008, pp. 973-978.

[9]  “Physician-assisted suicide: A family struggles with the question of whether mom is capable of choosing to die,” Oregonian, February 4, 2015. Available at: http://www.oregonlive.com/health/index.ssf/2015/02/physician-assisted_suicide_a_f.html (last accessed 4/20/15).

[10]  Ibid.

[11]  Section 142.E.2 (3) (definition of “competent”).

[12]  Section 142.E.4 (1).

[13]  Section 142.E.5 (1).

[14]  Section 142.E.5 (2) (a).

[15]  Section 142.E.5 (2) (b) (2).

[16]  For example, statistics indicate, “Only four percent of reported elder abuse cases come from the elder person; 96 percent of the reports come from somewhere else.” Gazette.net (Maryland), “A safe place for abused seniors,” February 9, 2015. Available at http://www.gazette.net/article/20150209/NEWS/150209456/1007&source=RSS &template=gazette (last accessed February 16, 2015).

[17]  Section 142.E.6 (1) (k) (2) (b).

[18]  Official report for 2014 deaths under Oregon’s Death with Dignity Act, pg. 5.  Available at:     http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/ year17.pdf  (last accessed 4/6/15).

[19]  Section 142.E.14 (5) (a) (emphasis added).
Note: a health care facility is included in the definition of “health care provider.” Section 142.E.2 (8).

[20]  Section 142.E.14 (5) (d) (1) (definition of “action under this chapter”).

[21]  Section 142.E.2 (9) (e).

[22]  KATU Television, “Letter noting assisted suicide raises questions” (interview about one such case and the response of the Oregon Health Plan). Available at: http://www.katu.com/news/26119539.html (last accessed 1/29/15).

[23]  “The Oregon Experience.” Available at: http://www.patientsrightscouncil.org/site/the-oregon-experience (last accessed 1/30/15).