This 2019 bill is an attempt by doctor-prescribed suicide activists to transform assisted suicide into a “medical treatment.” It is patterned after Oregon’s “Death with Dignity Act.”
Under SB 165:
Doctor-prescribed suicide would become a “medical treatment.”
SB 165 specifically defines “dispensing a controlled substance designed to end the life of a patient” as a “medical treatment.”[1]
Once assisted suicide becomes a medical treatment, it is the least expensive medical treatment that is available. This gives insurance programs the opportunity to cut costs by denying payment for more expensive treatments while approving payment for the least expensive “medical treatment” – a prescription for a lethal drug overdose.
This has happened in Oregon – the state with the law upon which the Nevada bill is based – as well as in California. 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]
In California, after finding that her insurance company would not cover the chemotherapy her doctor had prescribed, a woman asked if assisted suicide was covered under her plan. She was told, “Yes, we do provide that to our patients, and you would only have to pay $1.20 for the medication.”[4]
California pays for assisted-suicide drugs obtained under the state’s doctor-prescribed suicide law.[5]
If the Nevada bill is approved, will health insurance programs do the right thing – or the cheap thing?
Under SB 165, the most marginalized individuals – poor, hardworking people – would be in particular danger.
“Choice” is an appealing word. But inequity in health care is a harsh reality.
Under SB 165, before writing the prescription for drugs to end a patient’s life, the attending physician is to inform the patient of all “feasible alternatives.”[6] However, discussing all alternatives does not mean patients have the ability to access those options.
Even patients who have insurance may find that it does not cover the “feasible alternatives.” So, if SB 165 passes, assisted suicide may become a “choice” for the comfortably well off, but the only “medical treatment” the poor can afford.
An individual with a controllable medical condition could be considered to have a terminal condition, making him or her eligible for doctor-prescribed suicide.
To be eligible for a suicide prescription, a patient is considered to have a terminal condition if the condition is “an incurable and irreversible condition that cannot be cured or modified” and “will, in the opinion of the attending physician, result in death within 6 months.”[7]
There are many conditions (diabetes, certain types of leukemia, disabilities requiring ventilator support, etc.) that, although they cannot be cured or modified, they can be controlled. And, 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 official reports from Oregon, diabetes is noted as the underlying terminal condition that made the patient eligible for a lethal prescription.[8]
Why is the definition of “terminal condition” so broad?
Severely depressed or mentally ill patients could receive doctor-prescribed suicide, without having any form of counseling or mental examination.
Even if the patient is severely depressed or mentally ill, a physician is not required to refer the patient for an examination by a psychiatrist or psychologist unless the physician believes the patient may not be “competent.”[9] “Competent” means the person has the ability to make, communicate and understand the nature of decisions concerning his or her health care.[10]
This provision is similar to that contained in Oregon’s law where in the twentieth year of that state’s law, fewer than 4 percent of the 143 patients who received lethal prescriptions were referred for a psychological evaluation.[11] A study about Oregon’s law found that it “may not adequately protect all mentally ill patients.”[12]
“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 be unable to understand the nature of decisions about health care, the bill does not prohibit a health provider, family member or another person from arranging for the patient to be evaluated by other mental health professionals until one is found who would declare that 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.”[13]
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.[14]
Family members or health care providers and others could advise, suggest, encourage or exert subtle pressure on vulnerable individuals to request doctor-prescribed suicide.
The bill states that witnesses to the written request must attest to the fact that the patient “appears to be of sound mind and not under duress, fraud or undue influence.”[15] 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.[16] 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.
A person who would benefit financially from the person’s death could pick up and deliver the lethal prescription to the patient.
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 the fear of being a burden to others.
In Oregon’s twentieth official report, fear of being a burden on others was given as a reason for requesting lethal drugs by more than 55% of those who died using that state’s assisted-suicide law.[18]
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 ensure 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 aren’t there any safeguards at the most important part of the process – at the time the patient takes the drugs that will cause death?
The death certificate would not reflect the actual cause of death.
The bill requires that the attending physician sign the death certificate of a “patient who dies after self-administering a controlled substance that is designed to end the life of the patient” and that the terminal condition with which the patient was diagnosed, rather than the lethal overdose, must be listed as the cause of death.[19]
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[1] Section 30. 9 (b) (2).
[2] Sue Donaldson James, “Death Drugs Cause Uproar in Oregon,” ABC News, August 6, 2008. Available at: http://abcnews.go.com/Health/story?id=5517492&page=1. (Last accessed 2/19/19.)
[3] Oregon Dept. of Human Services, “FAQs about the Death with Dignity Act” p. 4. Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/faqs.pdf. (Last accessed 2/19/19.)
[4] Bradford Richardson, “Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman,” Washington Times, October 20, 2016. Available at: http://www.washingtontimes.com/news/2016/oct/20/assisted-suicide-law-prompts-insurance-company-den. (Last accessed 2/19/19.)
[5] Kimberly Leonard, “Californians Can Choose to Die – With the Help of Taxpayers,” U.S. News & World Report, March 21, 2016. Available at: https://www.usnews.com/news/articles/2016-03-21/in-california-government-to-pick-up-the-tab-for-death-with-dignity. (Last accessed 2/19/19.)
[6] Section 14. Written request form.
[7] Section 10.
[8] Official report for deaths under Oregon’s Death with Dignity Act in Year 20, Oregon Public Health Division, “Oregon’s Death with Dignity Act,” pg. 9 and pg. 11, fn. 1 and 2. Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year20.pdf. (Last accessed 2/19/19.)
[9] Section 16. 1 (a).
[10] Section 5.
[11] Official report for deaths under Oregon’s Death with Dignity Act in Year 20, Oregon Public Health Division, “Oregon’s Death with Dignity Act,” pg. 10. Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/ year20.pdf. (Last accessed 2/19/19.)
[12] 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.
[13] “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 2/19/19.)
[14] Ibid.
[15] Section 14. Written request form – declaration of witnesses.
[16] Section 13. 1 (b) (2).
[17] Section 17. 3 (c).
[18] Official report for deaths under Oregon’s Death with Dignity Act in Year 20, Oregon Public Health Division, “Oregon’s Death with Dignity Act, ” pg. 10. Available at: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/ year20.pdf. (Last accessed 2/19/19.)
[19] Section 1. 3.
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