Vermont recently became the fourth state in the US—after Montana, Washington and Oregon—to pass a law allowing doctor-assisted suicide (DAS).
It’s a controversial issue, to say the very least. But no matter what your personal views on the topic, it’s important to understand how it works, especially since the concept is spreading. For instance, lawmakers in New Jersey, Connecticut, Massachusetts, Kansas, Hawaii, New Hampshire and Pennsylvania all have recently considered assisted-suicide legislation, and more states are likely to follow—so it’s not a topic that can easily be ignored.
What really happens during DAS? For the straight answers, Daily Health News interviewed Sherwin B. Nuland, MD, a clinical professor of surgery at Yale School of Medicine, fellow of the Yale Institution for Social and Policy Studies, and founding member of the Bioethics Committee at Yale New Haven Hospital. Dr. Nuland also is a fellow and board member of the Hastings Center, an independent bioethics research institution, and author of How We Die: Reflections on Life’s Final Chapter, which won a National Book Award.
Here’s what Dr. Nuland had to say in answer to our questions…
Q. How is DAS done? Is it a pill? Injection?
A. It’s an oral medication, a barbiturate—usually a pill but sometimes a liquid. It can’t be an injection, because the doctor cannot directly cause the patient’s death by administering the drug. Rather, the doctor is “assisting” in that he or she is writing the prescription. Insurance may cover the cost of the drug, which is generally under $100.
Q. Why use an oral drug versus another method?
A. Doctors, by their ethical code, are not permitted to kill patients…and I believe that most doctors, based on their own sense of morality, would not want to do that. Some doctors wouldn’t be willing even to prescribe pills that would be fatal. But others consider this to be a type of “assistance” that is not the same as actually causing a patient’s death.
Q. What typically happens after the drug is taken?
A. Pretty quickly you fall into a deep sleep, then you stop breathing. It should take less than an hour, though in some cases it takes much longer–depending on many variables, such as the patient’s size, whether the patient is able to swallow the full dosage and whether any of the drug is vomited up. In the state of Washington, for instance, reported times from ingestion of the drug to death have varied from nine minutes to 28 hours.
Q. In states where DAS is legal, can a person include a preference for DAS in his/her living will or advanced health-care directive?
A. No. You can indicate in those documents that you don’t want to be kept alive by life support—in other words, if you have a disease or injury that would cause your death if artificial means of sustaining life were not being used. But that is very different from choosing to commit suicide, even with the assistance of a doctor.
It’s important to note that in order to be eligible for DAS, a person must be at least 18 years old and must have a medical condition that is expected to cause his death in six months or less.
Q. If you reside in a state where DAS is not legal, can you go to one of the four states where it is legal and get a prescription for the lethal drug from a doctor there?
A. No, you have to be a resident of the state. In my view, no state would want to become known as the “death state” for residents of other states. However, there is no minimum time restriction on residency.
If you live in a state where DAS is not legal, you could contact an advocacy group such as Compassion and Choices, which can put you in touch with an end-of-life counselor who could explain your options.
Q. Is a psychiatric evaluation required prior to DAS?
A. No, and I think that this is one of the big problems with these laws. You need two doctors to get the prescription—one is your own doctor and the other is a consulting doctor—but neither of them is required to provide a psychiatric consultation unless one or both doctors feel that the patient is not mentally competent to make and communicate health-care decisions. But I think that an awful lot of people nearing the end of life become severely depressed and their judgment is markedly impaired—and if their depression were treated, perhaps they wouldn’t want to hasten their own deaths.
State laws do require that a person make three requests before a DAS can happen. First there must be an oral request made to your physician, who must be licensed in the state where you live. Then after a mandatory 15-day waiting period, there must be a second oral request along with a written request that is witnessed by two people. After that, there is a 48-hour waiting period before the prescribed lethal medication can be picked up from the pharmacy.
Q. What if a person requests DAS and his own doctor refuses to do it?
A. Doctors are not obligated to participate in DAS. The patient could say, “Can you recommend someone who is willing to do it?” Maybe the patient’s doctor will be able to provide a referral. You also should note that pharmacists are not required to fill the prescription for DAS medication, nor are they obligated to suggest a pharmacy that will.
Q. Does the person requesting DAS have to let his family know about the plan?
A. The patient’s physician must request that the patient notify his next of kin, but there is no requirement for the patient to actually follow through. For instance, your doctor can say, “I think it’s a good idea to tell your spouse.” But if you say, “I’m not going to tell my spouse,” then a physician who would otherwise be willing to participate in DAS wouldn’t refuse your request based solely on your decision not to notify your family.
Q. What if a loved one tells me that he wants DAS? What could I say to that person, particularly if I don’t want him to go through with it?
A. Most people do discuss this decision with their families. If you disagree with your loved one’s decision, you might say, “I couldn’t bear it if you went ahead with this. I know that you are suffering, but please, let’s thoroughly explore all other alternatives before you make any irrevocable decisions.”
Q. But what if the person is in terrible pain and on the road to death? Might not DAS offer a better alternative than continued suffering?
A. “Better” is something that is defined by each individual. There are two choices you’re describing—remain in unbearable pain or commit DAS. But you are leaving out a third option, which is to receive proper palliative care. An awful lot of people don’t even know that palliative care exists—yet in many cases, pain can be significantly reduced. That’s why I would encourage the patient not to make the decision for DAS until he has talked with a palliative care specialist. In fact, before participating in DAS, a physician is required to notify the patient about alternatives to suicide, including palliative or “comfort” care, hospice care and pain management.
Q. Dr. Nuland, what would be the ideal safeguards needed to make you, personally, more comfortable with DAS?
A. There should be no DAS without a psychiatric consultation and no DAS without a required palliative care consultation with the patient. Also, there should be no DAS without the closest family member knowing about it, because I personally believe this is a horrible thing to do to those left behind—severe and possibly lasting emotional harm might occur to a family member.
Another objection I have to DAS is that there’s always the possibility that the patient is being coerced by a family member, and there is nothing in these laws to guard against that. Not everyone loves his or her family members the way you do. There are people who want their ill, elderly parent or other relative off the scene. I don’t know how to guard against that.
Q. In states where DAS is legal, how many are performed each year?
A. Not very many. For instance, in 2012, there were 115 prescriptions filled in Oregon, of which 77 were taken. In the three years since the state of Washington first allowed DAS, 255 patients have obtained lethal prescriptions…40 of these were for terminally ill cancer patients, and of those 40 prescriptions, only 24 were used.
One interesting thing that I have observed about the DAS controversy is that, while there are a fair number of people who support such laws because they want to know that they have the right to choose DAS, once they have that right, they don’t seem to consider it as a real option for themselves.
