Life, Liberty, and the Pursuit of a Peaceful End: Medical Aid in Dying in the U.S.
An examination of medical aid in dying legislation
On April 9, 2024, Colorado's SB 068 safely passed its third reading in the House, putting it well on its way to becoming law. The bill modifies the existing laws around 'medical aid in dying', which allows a terminally ill individual to request life-ending medication from a physician. The proposed changes include authorizing advanced practice registered nurses to evaluate individuals and prescribe the medication and reducing the mandatory waiting period between oral requests from 15 days to 48 hours. It also forbids insurers from denying or altering benefits for individuals with terminal illnesses based on the availability of medical aid-in-dying, and from coercing such individuals to request this form of medication.
The introduced version also eliminated the requirement for the individual to be a state resident, which would have allowed terminally ill people from anywhere in the US to travel to Colorado to end their lives. This provision was stripped out in committee.
Colorado is not alone in seeking to change laws around assisted dying, so let's take a look at how we got here and the laws currently making their way through legislatures around the country.
Historical Context
In recent years, the debate over assisted dying has continued to evolve, with various states across the U.S. adopting legislation to address the complex issues surrounding end-of-life decisions.
The concept of assisted dying in America traces back to Oregon’s pioneering Death with Dignity Act in 1997, which was the first law in the U.S. allowing terminally ill patients to end their lives through self-administered lethal medications. between 1997 and 2022 almost 2,500 people have chosen to end their lives in Oregon. Following Oregon, nine other states and Washington D.C. have enacted similar laws:
Only two states, however, have enacted legislation which allows non-residents to end their lives there - Oregon and Vermont. California has also introduced a similar bill, which as of April 2024 was still in committee.
It's notable that nine out of the 10 states, and D.C., are Democrat-led. Montana is the outlier, and was the only state where medical aid-in-dying was legalized through the courts rather than the legislature. As Compassion & Choices explain, in 2008 a Montana judge found that Montana had a constitutional right to allow “a competent terminally ill patient to die with dignity.” The ruling was upheld by the Montana Supreme Court and since then there have been attempts to legislate on the matter, such as SB 210 in 2023 which sought to criminalize "physician aid in dying", opening doctors up to homicide charges. The bill was narrowly defeated in the Senate 52% to 48% with 10 Republicans joining all Democrats in voting it down.
The trajectory of other laws across the country has been marked by an increasing emphasis on safe, ethical practices that protect both the patient's rights and the medical professionals involved. Each iteration of the law in new states tends to include more detailed safeguards and broader definitions of who can participate in the process, reflecting ongoing ethical debates and the evolution of medical practice. Colorado has been at the forefront of this movement, having initially legalized medical aid-in-dying in 2016 through a voter-approved ballot initiative.
So why are there so many of these bills now, and why is it such a partisan issue?
Differing Viewpoints
We are, on average, living longer. In 1900, the average life expectancy of a newborn was 32 years. By 2021 this had more than doubled to 71 years. A lot of this increase is due to reduced infant mortality, but mortality has fallen for most age groups, so more and more of us can expect to live well into our eighties or even past 100. This increased lifespan has not been matched with an increase in healthy life, meaning more elderly people suffering from chronic illnesses and disabilities which severely affect their quality of life. It's unsurprising that people in such situations, rather than enduring weeks, months or years more of suffering, often at great expense for their family, want the option to end their life their way, with dignity.
Supporters believe that allowing terminally ill individuals to choose a peaceful end is an act of compassion. It prevents unnecessary suffering and preserves the dignity of the individual in their final days, offering a controlled and humane way to manage death. This view prioritizes personal liberty, a fundamental principle highly valued in various aspects of American life.
“It comes down to the right of an individual to control their own end of life decisions free from government intervention or religious interference,” said Goeff Sugerman, national campaign strategist for Death with Dignity.
Opponents often cite religious and ethical principles stating that life is sacred and only a higher power has the right to end it. This view is deeply rooted in the beliefs of many major religions, which influence much of the conservative viewpoint. Critics further argue that the laws could be abused to pressure vulnerable individuals, such as the elderly or disabled, into ending their lives prematurely. They worry about the potential for economic coercion, particularly in a healthcare system where costs are high and insurance coverage may be inadequate.
“It’s normalizing suicide, and it’s incentivizing individuals to end their lives,” said Danielle Pimentel of Americans United for Life. Pimentel raised concerns that pain isn’t the top reason people choose an early departure, adding that policy should focus on bettering end-of-life care.
There is also concern that once medical aid in dying is legalized, the criteria may gradually expand to include non-terminal illnesses or even mental health issues, fundamentally altering societal values about life and death. Canada, where medical aid in dying has been legal since 2016, recently pushed back plans to allow an extension to mental illness. “The Government of Canada recognizes that mental illness can cause the same level of suffering as that of physical illnesses,” the health department said in a statement. “However, in its consultations with the provinces, territories, medical professionals, people with lived experience and other stakeholders, the Government of Canada has heard – and agrees – that the health system is not yet ready for this expansion.”
The opposing arguments reflect broader political ideologies. Democrats often prioritize human dignity and the right of the individual to choose for themselves. Republicans, with a strong base in religious and conservative communities, emphasize traditional moral values and the potential societal impacts of altering laws around life and death. The division is also influenced by differing views on the role of government. Democrats may see government as a facilitator of personal choices and freedoms, while Republicans might view its role as protecting societal morality and preventing potential abuses.
Regardless of the political divisions, support for assisted dying remains strong. A 2018 Gallup poll showed more than two-thirds of Americans support it. The support is reflected in the legislation now passing through state legislatures.
Current Legislation
This stakeholder page lists over 60 bills in current sessions around the country that are related to medical aid-in-dying. Several have become law: including the Vermont bill to remove residency requirements from its existing provisions. Hawaii's HB 650 is similar to the Colorado bill in that it authorizes advanced practice registered nurses to practice medical-aid-in-dying and reduces the mandatory waiting period between the two oral requests required for a qualified patient to obtain a prescription for medication from twenty to five days. Washington's SB 5179 broadens access to the provisions of its Death with Dignity Act by clarifying concepts such as which medical providers are authorized to assist a patient to end their life.
Democrats in a number of states have introduced legislation to legalize medical aid in dying, with most bills still waiting in committee: Minnesota, New York, Arizona, Delaware (passed the House), Iowa, Kentucky, and Massachusetts. Bills in Virginia, Wisconsin, and Indiana were introduced but have already failed.
In New Jersey, Republicans are trying to repeal the existing law, but the bill doesn't seem to be making any progress. West Virginia has gone further, and actually amended its constitution to provide 'protection against medically assisted suicide'. The bill passed easily, despite Democrats largely voting against.
The debate will continue, and it's likely the number of states allowing some kind of aid in dying will continue to rise. This evolving legal landscape challenges us to consider deeply personal questions about life, death, and autonomy in the modern age.
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