Source: https://vtethicsnetwork.org/medical-ethics/pad
Timestamp: 2020-02-17 03:10:05
Document Index: 152938344

Matched Legal Cases: ['§ 5283', '§5283', '§5285', '§ 5285', '§ 1871', '§ 1909', '§ 1909', '§ 1871', '§ 127', 'art 1306']

Physician Assisted Death / Physician Aid in Dying / Act 39
Medical Ethics>Physician Assisted Death (PAD)
There is no national consensus about this practice, known as Physician Assisted Death or “PAD” (sometimes also referred to as “Physician Aid in Dying,” or “Physician Assisted Suicide.”) The US Supreme Court has twice held that the US Constitution does not create a right to PAD. However, the Court left open the possibility that state law could permit the practice, and suggested that the many moral, philosophical and practical issues involved might best be worked out in the “laboratory of the states.” Vermont is now part of this experiment.
The Vermont Ethics Network recognizes that while Vermonters hold a diversity of views in regard to PAD, the practice is now another legal end-of-life care option in this state. Consistent with our mission to promote understanding of ethical issues in health care, VEN encourages Vermont citizens, health care providers and facilities to thoroughly inform themselves about the new law. The materials below provide information about Vermont’s new law, describe Physician Assisted Death (PAD) in general, provide some ethical perspectives, and offer both legal and historical background information regarding the major arguments for and against the practice.
Background: The Vermont Legislature passed a law that makes it legal for a terminally ill, capable adult patient to request and obtain a lethal prescription of a medication to be self-administered for the purpose of hastening the patient’s death (18 V.S.A. Chapter 113 § 5283).
Participation in Vermont’s Patient Choice at the End of Life law is voluntary. Patients should be aware that health care facilities have the option not to participate in the law and to institute policies that would restrict physicians from participating.
Have a terminal condition with a life expectancy of 6 months or less
Make an initial voluntary oral request to the physician (in the physician’s physical presence) for medication to be self-administered for the purpose of hastening their own death.
Make a second voluntary oral request no fewer than 15 days after the first oral request (in the physician’s physical presence) for medication to be self administered for the purpose of hastening their own death. (At the time of the second request, the physician must offer the patient an opportunity to rescind the request.)
Make a written request for medication to be self-administered for the purpose of hastening death. The written request must be signed in the presence of two (2) witnesses who are at least 18 years of age and who sign and affirm that the patient appeared to understand the nature of the document and to be free from duress or undue influence at the time the request was signed. Witnesses cannot be:
a patient’s relative by blood, civil marriage, civil union or adoption;
a person who knows that s/he would be entitled, upon the patient’s death, to any portion of the estate or assets of the patient under any will or trust, by operation of law, or by contract; or
their diagnosis and prognosis, including an acknowledgement that the predicted life expectancy is an estimate based on the physician’s best medical judgment, is not a guarantee of the actual time remaining in the patient’s life and that the patient could live longer than the time predicted;
the range of treatment options appropriate for the patient and the diagnosis;
all feasible end-of-life services including palliative care, comfort care, hospice care and pain control;
Be referred for a second opinion to confirm the diagnosis, prognosis, and determination that they are capable, are acting voluntarily and have made an informed decision and do not have impaired judgment.
Be informed that they may rescind their request at any time and in any manner.
Pick up their prescription in person or have it picked up by the patient’s expressly identified agent.
It is also recommended that patients seeking to obtain a prescription for the purpose of hastening their own death also have a Vermont DNR/COLST form signed by their physician. This will help to ensure that the patient’s preferences are respected in the event that emergency services are called.
Background: The Vermont Legislature passed a law that makes it legal for a terminally ill, capable adult patient to request and obtain a lethal prescription of a medication to be self-administered for the purpose of hastening the patient’s death. (18 V.S.A. Chapter 113 §5283)
Participation in Vermont’s Patient Choice at the End of Life law is voluntary. Per §5285 of 18 VSA Chapter 113, a health care facility shall not subject a physician, nurse, pharmacist, or other person to discipline, suspension, loss of license, loss of privileges or other penalty for participating in or refusing to participate in Vermont’s Patient Choice at the End-of-Life law.
Definition: Health care facility is defined as all persons or institutions, including mobile facilities, whether public or private, proprietary or not for profit, which offer diagnosis, treatment, inpatient, or ambulatory care to two or more unrelated persons, and the buildings in which those services are offered. The term shall not apply to any institution operated by religious groups relying solely on spiritual means through prayer for healing, but shall include but is not limited to:
The patient intends to use the medication on that facility’s premises; and
The following are recommendations only and are not specifically addressed in the statute. Further, they do not represent all possible considerations for a facility. However, a facility may find it beneficial to consider them in advance so as to avoid confusion and potential conflict in the future:
It may be relevant to consider when to notify patients of the facility’s position on Patient Choice at the End of Life, and whether that facility is a participating one.
Facilities that may employ physicians from other facilities (i.e. hospitals and hospice program medical directors) may want to consider proactive discussions if the facilities have different policies in regard to participation in Vermont’s Patient Choice at the End of Life law. Addressing competing policies in advance may alleviate or eliminate potential conflicts for physicians in these situations.
Participation in Vermont’s Patient Choice at the End of Life law is voluntary. Per section 5285 of 18 VSA Chapter 113, a physician, nurse, pharmacist, or other person shall not be under any duty, by law or contract, to participate in the provision of a lethal dose of medication to a patient. Further, a health care facility or health care provider shall not subject a physician, nurse, pharmacist, or other person to discipline, suspension loss of license, loss of privileges or other penalty for participation or refusal to participate in Vermont’s Patient Choice at the End-of-Life law.
Under the new law, a health care facility may prohibit a physician from writing a prescription for a lethal dose of medication when all 3 of the following conditions exist:
Inform the patient of their right to rescind their request at the time that the second oral request is made (which can be no fewer than 15 days after the first oral request).
Dispense the medication directly (if they are licensed to dispense medication in Vermont); or contact a pharmacist (with the patient’s consent) and inform the pharmacist of the prescription, and deliver the written prescription personally, by mail or by fax to the pharmacist.
The date, time and wording of all oral requests of the patient for medication to hasten death.
Physician Reporting Form	Consulting Physician Reporting Form
It is also recommended that physicians complete a Vermont DNR/COLST order for patients who have obtained a lethal prescription for the purpose of hastening their own death. This will help to ensure that the patient’s preferences are respected by responding emergency personnel in the event that emergency services are called.
Participation in Vermont’s Patient Choice at the End of Life law is voluntary. Per § 5285 of 18 VSA Chapter 113, a physician, nurse, pharmacist, or other person shall not be under any duty, by law or contract, to participate in the provision of a lethal dose of medication to a patient. Further, a health care facility or health care provider may not penalize a physician, nurse, pharmacist, or other person based on their participation or refusal to participate in the law.
However, the new law does not alter the rights and duties existing under Vermont’s Patient’s Bill of Rights, 18 V.S.A. § 1871, or under 12 V.S.A. § 1909 regarding informed consent.
“The rights of a patient under Section 1871 of this title to be informed of all available options related to terminal care and under 12 V.S.A. § 1909(d) to receive answers to any specific question about the foreseeable risks and benefits of medication without the physician’s withholding any requested information exist regardless of the purpose of the inquiry or the nature of the information. A physician who engages in discussions with a patient related to such risks and benefits in the circumstances described in this chapter shall not be construed to be assisting in or contributing to a patient’s independent decision to self-administer a lethal dose of medication….”
18 V.S.A. § 1871. Patient’s bill of rights for palliative care and pain management:
While not required by the statue, it is recommended that physicians have comprehensive discussions with patients about their goals for care and their treatment preferences, and that they assist patients, if needed, in completing advance directives to document the patient’s health care goals, values and preferences.
See the Vermont Department of Health’s FAQ list pertaining to Act 39: The Patient Choice and Control at End of Life Act.
Physician Aid in Dying (aka Physician Assisted Death or Physician Assisted Suicide, "PAD") Physician prescribes drug(s) to a competent terminally ill patient, upon the patient's request, with the understanding that the patient intends to use them to end his or her own life.
Voluntary Active Euthanasia Intentional, direct administration of drugs or other interventions to cause the death of a competent adult patient when the patient has explicitly requested and consented to it.
Involuntary Active Euthanasia Intentional, direct administration of drugs or other interventions to cause a patient's death over the patient's objection.
Non-Voluntary Active Euthanasia Intentional, direct administration of drugs or other interventions to cause a patient's death when the patient is incompetent and incapable of explicitly requesting or consenting to it (e.g. patient is in a coma).
Involuntary and Non-Voluntary euthanasia are considered murder and are illegal everywhere in the U.S. Involuntary euthanasia is regarded as morally wrong because it violates a patient’s right not to be killed. Non-voluntary euthanasia is considered morally wrong because it might be applied selectively to the disadvantaged and the vulnerable.2
Voluntary active euthanasia is also illegal everywhere in the U.S. The key difference between physician aid in dying and voluntary active euthanasia as defined above is in who acts to end the patient’s life. In physician aid in dying, the physician prescribes the lethal drug, but the patient decides when and whether to self-administer it. In voluntary active euthanasia, a third party directly administers the drug or other intervention that ends the patient’s life.
Every competent adult has the right to refuse unwanted life-sustaining treatment (respirators, feeding tubes, etc). There is consensus in state law, in health care ethics and in the medical profession that the patient’s decision should be respected.
1Adapted from Emanuel, Ezekiel, “Euthanasia: Historical, Ethical, and Empiric Perspectives,” Arch Intern Med (9/12/94): 154, quoted in Report of the Vermont Legislative Council’s Office, Oregon’s Death with Dignity Law and Euthanasia in the Netherlands: Factual Disputes (2004)
3NP Sykes, “Morphine kills the pain, not the patient,” Lancet 369 (2007): 1325-6
Ethical Issues Surrounding Physician Aid in Dying
Justice: Justice requires us to “treat like cases alike.” Competent, terminally ill patients have the legal right to accept or refuse treatment that will prolong their deaths. For patients who are terminally ill but who are not dependent on life support, refusing treatment will not bring death quickly. To treat these patients equitably, we should allow physician assisted death as it is their only option to hasten death.2
Compassion: Suffering means more than pain. There are other physical, spiritual, existential, social and psychological burdens such as the loss of independence, loss of sense of purpose and meaning, and functional capacities that some patients feel jeopardize their dignity. It is not always possible to relieve suffering. Thus, PAD may be a compassionate response to unremitting suffering.
Individual liberty vs. state interest: Though society has a strong interest in preserving life, that interest lessens when a person is terminally ill and has a strong desire to end life. A complete prohibition against PAD excessively limits personal liberty. Therefore, PAD should be allowed in certain cases.
Passive vs. active distinction: There is an important difference between passively “allowing to die” and actively “killing.” It is a patient’s right to refuse any medical treatments (including food and hydration) at any time. A valid refusal of treatment that allows a person to die (passive) is justifiable, whereas PAD equates to killing (active) and is not morally justifiable.5
Protection of the ethical integrity of the medical profession: Historical ethical traditions in medicine are strongly opposed to taking life. Some major professional groups (American Medical Association, American Geriatrics Society) oppose physician assisted death. The overall concern is that linking PAD to the practice of medicine could harm both the integrity and the public’s image of the profession.
For additional discussion of positions for and against PAD, VEN recommends Top 10 Pros and Cons at ProCon.org.
1Adapted from Bioethics Topics, Physician Aid in Dying, University of Washington School of Medicine
3 Adapted from Bioethics Topics, Physician Aid in Dying, University of Washington School of Medicine
4See Cruzan v. Director, Mo Dep’t of Health, 497 U.S. 261, 287 (1990).
The question whether a severely ill patient should be able to obtain a physician’s assistance in ending his or her life is almost as old as the practice of medicine itself. The prevailing opinion in Western medicine, as expressed in the Hippocratic Oath, has rejected this practice: “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan.”
The law is in accord. While suicide is not a crime in Vermont or any other state, assisted suicide is generally understood to be a crime under common law.
In recent decades, patients have become more active in medical decision-making. No longer are medical decisions left exclusively in the hands of medical professionals. Courts have become involved in determining the appropriate balance between patients and medical-care providers in decision-making, and have established a limited “right to die.” The right to die is a negative right, meaning that competent individuals have a constitutional right to refuse unwanted medical treatment, even when doing so will result in death. At stake in the debate over physician aid in dying is whether in some circumstances there might also be a positive right to die (i.e., a right to assistance in hastening death). The U.S. Supreme Court has twice ruled that the U.S. Constitution does not establish a positive right to physician assistance in dying.1 However, those two cases left open the possibility that the right might exist in very narrow circumstances not present in those cases, or that state law might confer such a right. The Court explicitly suggested that the “laboratory of the states” is a better forum to work out the many moral, philosophical and practical issues PAD brings up. Justice Sandra Day O’Connor stated:
Every one of us at some point may be affected by our own or a family member’s terminal illness. There is no reason to think the democratic process will not strike the proper balance between the interests of terminally ill, mentally competent individuals who would seek to end their suffering and the State’s interests in protecting those who might seek to end life mistakenly or under pressure.2
To date, most states prohibit PAD and no court has found a state constitutional right to PAD. Two states, Oregon and Washington, have statutes that authorize PAD under strictly controlled circumstances described below. Both statutes were passed by voter referendum. The Oregon law has withstood several court challenges and PAD has now been practiced there for over 13 years. In addition, Montana legalized PAD through a court decision in 2009; however, the Court in that case sidestepped the question of whether PAD is a state constitutional right and merely upheld the state law prohibiting prosecution of physicians for helping terminally ill patient die.3 Two state supreme courts have upheld state laws banning PAD. In Vermont, past legislative efforts to legalize PAD failed.
For a more detailed discussion of the constitutional legal issues involved in PAD, see Legal Analysis below.
1Vacco v Quill, supra; Washington v. Glucksberg, 521 U.S. 702 (1997)
2Washington v. Glucksberg, 521 US at 737 (1997) (O’Connor, J., concurring). See also: Cruzan v. Director Mo. Dep’t of Health, 497 U.S. 261, 292 (O’Connor, J. concurring) (1990).
3Baxter v. State, 354 Mont. 234, 224 P.3d 1211 (Mont. 2009).
Public Opinion Regarding PAD
1Physician Assisted Death, The Hastings Center
A patient must make one written and two oral requests for medication to end his or her life, the written one “substantially in the form” provided in the Act, signed, dated, witnessed by two persons in the presence of the patient who attest that the patient is “capable, acting voluntarily, and not being coerced to sign the request,” and there are stringent qualifications as to who may act as a witness. The patient’s decision must be an “informed” one, and the attending physician is thus obligated to provide the patient with information about the diagnosis, prognosis, potential risks, and probable consequences of taking the medication to be prescribed, and alternatives, “including but not limited to, comfort care, hospice care and pain control.” Another physician must confirm the diagnosis, the patient’s decision-making capacity, and voluntariness of the patient’s decision. There are requirements for counseling if the patient is thought to be suffering from a mental disorder which may impair his or her judgment, for documentation in the patient’s medical record, for a waiting period, for notification of the patient’s next of kin, and for reporting to state authorities. The patient has the right to rescind the request for medication to end his or her life at any time.
Having met the above requirements, the patient is entitled to a prescription for medication to end life. The Act does not “authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia.” That is, the Act authorizes physician assisted suicide by lethal prescription but explicitly rejects active euthanasia.2
Studies of the Oregon law to date indicate that PAD use is stable and relatively rare (460 deaths over the first 12 years).3 Pain management has improved, hospice use is among the highest in the country, and there is a state program to record Physician Orders for Life Sustaining Treatment (POLST).4 POLST forms (called COLST forms in Vermont) are medical orders signed by a physician that are intended to insure that a patient’s wishes to limit treatment are respected.
Given that Vermont has 1/6 the population of Oregon – and assuming the use of PAD would be similar to that of Oregon – we can predict that 3 Vermonters would obtain a lethal prescription in the first year of legalized PAD (2 would use it), subsequently reaching a maximum of 15 prescriptions per year (up to 9 patients would use them).
13 Or. Rev. Stat. § 127.800 (1994).
2Report of the Vermont Legislative Council’s Office, Oregon’s Death with Dignity Law and Euthanasia in the Netherlands: Factual Disputes (2004)
3See Death With Dignity Act Annual Reports, Oregon Dept of Human Services
4Physician Assisted Death, The Hastings Center
As medicine has advanced and to continues to advance, PAD has arrived at the intersection of constitutional privacy law and medical technology. Constitutional privacy law limits the government’s ability to intrude in personal choices. As technology advances and life can be preserved even if the individual patient does not find a quality to his/her life, what are the government’s legitimate interests? Government has a general interest in preserving life and prohibiting intentional killing and suicide. It may want to insulate terminally ill patients from undue influence from others who would want them to end their lives. It also has an interest in maintaining the integrity of the medical profession, in containing the cost of care, and in avoiding a slippery slope toward legal euthanasia. Courts examining PAD balance governmental interests against the individual’s autonomy.
As noted above, there have been two circumstances where the US Supreme Court has considered PAD, both on challenges by state stakeholders to the illegality of PAD under state law. See Vacco v. Quill, 521 U.S. 793 (1997); Washington v. Glucksberg, 521 U.S. 702 (1997). In both, the Court found no right to physician assistance in dying under the US Constitution, either as a matter of privacy or equal protection. Given the lack of a fundamental federal constitutional privacy or equal protection right to PAD, a state government may regulate PAD and make it illegal where its regulation is rationally related to a legitimate state interest. The Court found that the states’ interests in preserving life, preventing suicide, protecting the vulnerable and maintaining the integrity of the medical profession were sufficient to support statutes forbidding PAD. However, the Court acknowledged that the States have the freedom to offer their citizens more liberties than the minimum required under the federal Constitution.
Attorney General Ashcroft did not agree that the issue of PAD is best left to the states. In 2002, he sought to enforce the federal Controlled Substances Act against Oregon practitioners who prescribed or filled prescriptions for controlled substances to be used in accordance with Oregon’s statute. 21 C.F.R. part 1306 (2002). When Oregon sued to challenge the actions of the Attorney General, the Supreme Court found that the federal Controlled Substances Act could not be used to declare a medical standard of care and treatment authorized under state law to be illegitimate: Gonzales v. Oregon, 546 U.S. 423 (2006).
Bills, Acts & Resources
Euthanasia Pros & Cons
2018 Report Concerning Patient Choice at the End of Life 2020 Report Concerning Patient Choice at the End of Life