However, if we learned anything from the story of Brittany Maynard — the beautiful 29-year-old newlywed with terminal cancer who very publicly chose to end her own life — it's that these are conversations we desperately need to have. Ultimately, it's a personal decision but it's one that impacts so many other people that it can't be made alone, especially when a terminally ill patient requires the help of a physician to carry out their wish to die.
And so we need laws — right-to-die laws that both respect the patient and their loved ones. But as you quickly discover, even if you think you know how you feel about end-of-life assisted suicide, the details are confusing and the ethics get murky fast.
In the wake of the passing of California's controversial Death With Dignity law here are five things you need to know about the legality of end-of-life suicide:
Understand the differences between types of end-of-life suicide. There are two ways to die: Passive and active. While examples of active suicide, like a patient taking a lethal dose of a drug, grab most of the headlines around assisted suicide, passive suicide is far more common. This involves the person hastening their own death by refusing or neglecting medical care. Medical patients can make living wills and/or DNR (do not resuscitate) orders that specify what lengths they approve for prolonging their own lives. For instance, a patient may refuse chemotherapy that will likely only prolong their life, not save it. Or a patient could neglect mechanical assistance like a feeding tube or a ventilator, choosing then to die from starvation or suffocation.
Physician-assisted suicide is the most controversial method. Physician-assisted suicide is defined as: a doctor knowingly and intentionally providing a person with the knowledge, means or both required to commit suicide, including counselling about lethal doses of drugs, prescribing such lethal doses or supplying the drugs.
Because this involves an active decision by an outside party to end the person's life, it is illegal in most states (see #5 below) and is often considered murder. It is this type of suicide that "right-to-die laws" mainly fight for. (Note: This is not the same as passive euthanasia where a doctor euthanizes a patient who is no longer able to make medical decisions for themselves which is illegal in every state.)
Know that every American has the right to make an advanced directive. Under the 1991 Patient Self-Determination Act, the law allows everyone to make a legal document called an advanced directive that spells out exactly what medical measures they will accept or refuse when it comes to their end-of-life care. This includes decisions that would be considered passive suicide. People can also give Medical Durable Power of Attorney to a friend or loved one who will then enforce the advanced directive and make end-of-life medical decisions on their behalf in the case the patient cannot.
Consider writing your Five Wishes. Rather than go through medical procedures one by one, you may choose to write your Five Wishes which allow you to state your priorities and values that you would like to be honored at the end of your life. This may include things like "I wish not to be in pain" or "I wish to die with my loved ones around me." While not as strong as an advanced medical directive, a Five Wishes document is generally considered legally binding.
Know the laws where you live. Thanks to the Patient Self-Determination Act, all states in the U.S. allow some passive forms of suicide. (Although the circumstances under which they're allowed to occur can differ from place to place, the PSDA is supposed to trump local laws in court.) However, "right to die laws" mainly cover active types of suicide like passive euthanasia, active euthanasia, assisted suicide and physician-assisted suicide. Only five states have these types of laws on the books.
How you're protected under the laws
Oregon, Washington, Vermont and California all now have a law that specifically allows only terminally ill adult patients to seek lethal medication from only their doctors. To qualify the patient must be a legal resident of that state, have less than six months to live, be of sound mind, make the request vocally and on paper, have it approved by multiple physicians, and then wait 15 days, followed by another request. In California, you also have to undergo a professional mental health evaluation.
In Montana, the state supreme court stopped short of permitting physician-assisted suicide, instead simply saying that nothing in state law prohibits it. They also provided legal protection for doctors listed in the supreme court case that wrote a prescription for lethal medication upon patient request. New Mexico currently has a similar case waiting to be heard by their supreme court.
For a state-by-state breakdown of all legislation — including laws that passed, failed, were modified or are still being heard — check out this map by Death With Dignity.
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