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On June 9, 2016, California’s “End of Life Option Act,” signed into law by Governor Jerry Brown last October, will go into effect. Under the law, patients who are at least 18 years old who have been diagnosed by a treating and a consulting physician with a terminal disease expected to result in death within 6 months may request aid-in-dying drugs. Verbal requests must be made 15 days apart and one must be signed, dated, and witnessed by two adults. A mental health assessment is not required unless the physician feels that there may be a mental disorder.
The drug will be dispensed to the patient and can be used anywhere although according to the guidelines, patients are being told not to use the drug in a public place and counseled that another person should be present. The law does not say how the cause of death should be indicated on the death certificate, but does indicate that using the drug “shall not constitute suicide.”
Physicians who participate will be exempt from criminal, civil or administrative liability. There is an exemption clause for physicians who do not wish to participate, and some hospitals, including Providence Health & Services, a Catholic hospital chain in Southern California indicated that it will not permit physicians to prescribe, or pharmacies to fill prescriptions for the drugs on hospital grounds.
The California Medical Association has posted guidelines on its website.
In Canada, according to an article by Barry Bussey, director of legal affairs at Canadian Council of Christian Charities and the former liaison of the Seventh-day Adventist Church to the U.S. Government, published March 9, 2016 in the National Post, a parliamentary committee has made recommendations that would expand assisted suicide legislation to include “those who were not terminally ill and, after a three year period, allow ‘mature minors’ to consent.” The report further called on government to “ensure that all publicly funded health care institutions [including church-based hospitals] provide medical assistance to the dying.”
Bussey predicts a coming “clash of wills” between government and Canada’s large Catholic health organizations. As he points out, “just because government gives money to a religious hospital does not mean that government gets to force what services that hospital will provide. The hospital, which is in the business of providing health care, says to the government, ‘This is what we do – do you want to fund it?’… If government wishes to require further ‘services’ that violate the conscience of the religious hospital, then it must go elsewhere. To say otherwise would be to turn freedom on its head. No person, and certainly no hospital, ought to be forced to take the life of another human being, no matter how moral or right the government may think it is.”
As it is being introduced, the California bill is much more restrictive than the scenario portrayed by the Canadian parliamentary committee in Bussey’s article, but court and legislative challenges amid rising medication, palliative and hospice health care costs may increase the pressure on the state to expand this to include a wider range of illnesses and conditions.
The humanitarian issues surrounding alleviation of pain cannot be viewed in isolation from the larger social issues involved. The cost savings to the Medicare system which pays the majority of the costs of treatment for terminal diseases, even if only a few participate in assisted suicide, could be significant. While an end of life drug may cost as little as $50, medication costs alone for the last six months of treatment of some kinds of cancer can be over $100,000, sometimes much more. A 2012 study of 28,530 patients published by the American Society of Clinical Oncology, “Health Care costs for Patients with Cancer at the End of Life” found that mean total cancer-related costs in the last 6 months before death were $74,212 when considered between inpatient, outpatient, and hospice care scenarios.
Although current numbers are unavailable, according to the California Health Care Foundation, 88,000 Californians sought hospice care in 2004.
In a sense, the costs of terminal healthcare have increased as a function of its own success as costly medications can prolong a more expensive life.
According to Modern Healthcare, reporting on March 11, 2016, at least two large California healthcare providers, Kaiser Permanente and Sutter Health have reportedly agreed to provide the life-ending drugs although individual physicians or pharmacists may opt out.
As the population ages, and more baby boomers (born between 1946 and 1964) enter the terminal care stage, they will be faced a newly legal moral dilemma between quickly and cost-effectively ending their lives or spending their last few months absorbing financial resources. The generation that obtained the right to legal abortion will also be the first to take widespread advantage of aid-in-dying.
We will continue to follow this legislation as it is implemented.