Analysis PA Doctor-Prescribed Suicide House Bill (2015)

HB 943 (2015)

Under the “Compassionate Autonomous Right for the End of Life” Bill (HB 943):

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 an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months.”[1]

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.[2]

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

If HB 943 is approved, doctor-prescribed suicide would become a “medical treatment.”

This would give insurance programs the opportunity to cut costs by denying payment of more expensive treatments while approving payment of the less costly prescription for a lethal drug overdose.

This has already been documented in Oregon – the state with the law upon which the Pennsylvania proposal 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.[3]

 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.”[4]

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

A health care facility could not prevent deaths from doctor-prescribed suicide on its premises.  Furthermore, a facility willing to permit assisted-suicide deaths could require nurses, pharmacists and certain other individuals to facilitate such deaths.

HB 943 states that “a health care provider may prohibit another health care provider from participating under this chapter on the premises” if certain notification is provided.[5]  (The definition of “health care provider” includes a health care facility or institution.[6])

It also states that “no health care provider may be under any duty, whether by contract, by statute or by other legal requirement, to participate in the provision to a qualified patient of medication to end his or her life in a humane and dignified manner.”[7]

However, the phrase “participate under this chapter” is very narrowly defined in the bill.[8]  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 ban 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.

Likewise, facilities permitting doctor-prescribed suicide could require pharmacists to dispense the lethal drugs and nurses to bring the drugs to a patient since such activities would not constitute “participation” as defined in the proposal.

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 individuals familiar with the patient’s manner of communicating if those individuals are available.”[9]

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?

As written, the bill would permit the oral requests to be conveyed by telephone and the written request to be electronically transmitted or delivered to the physician by a third party.

The individual is required to make two oral requests and one written request for doctor-prescribed suicide.[10]  However, there is no requirement that any of the requests be made in the presence of the attending physician.

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.[11]  Thus, one witness may be a potential heir who is 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.[12]

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.”[13]  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.[14]

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

Counseling is only required “if appropriate.”[15]

Even if the patient is severely depressed or has a mental illness, a physician does not need to refer the patient for counseling unless the physician believes the patient has “impaired judgment,” that prevents the patient from making an informed decision.[16]  If the depressed or mentally ill patient understands and acknowledges the relevant facts related to the request for doctor-prescribed suicide, he or she is considered able to make an informed decision and would not be referred for counseling.

All of the “safeguards” in the bill cease the moment the prescription is received.

The bill contains numerous references to the fact that the prescription is to be “voluntarily” requested.

Additionally, the patient is to be “capable” (have the ability to make and communicate health care decisions) and not suffering from impaired judgment when making the requests.

However, nothing in the bill states that the patient must voluntarily or even knowingly take them.

Furthermore, the bill’s written request form implies that the patient could lose capacity after receiving, but before taking, the lethal overdose.  It states, “I understand that this request will supersede any provision of an advanced directive to conflict with the provisions of this request.”[17] Since an advance directive only goes into effect after a person loses competence, this reference indicates that the patient may take the drugs even though no longer competent.

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?
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Note:  Supporters of HB 943 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.”[18]
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[1]  HB 943, Sec. 54B01. (Definition of “terminal disease”.)

[2]  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).

[3]  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).

[4]  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).

[5]  HB 943, Sec. 54B19 (b). (Emphasis added.)

[6]  HB 943, Sec. 54B01. (Definition of “health care provider.”)

[7]  HB 943, Sec. 54B19 (a). (Emphasis added.)

[8]  HB 943, Sec. 54B01. (Definition of “participate under this chapter”.)

[9]  HB 943, Sec. 54B01. (Definition of “capable.”)

[10] HB 943, Sec. 54B09.

[11] HB 943, Sec. 54B03 (b).

[12] 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).

[13] HB 943, Sec. 54B04 (a) (12) (ii) (B).

[14] 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).

[15] HB 943, Sec. 54B04 (a) (5).

[16] HB 943, Sec. 54B06.

[17] HB 943, Sec. 54B22.

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