1. Disposal People Physician Assisted Suicide and Vulnerable Populations

2. Road Map History and Evolution of PFS Current Legal Landscape in the US Ethical Concerns

3. THE NEW RIGHT TO DIE MOVEMENT

4. Battle Lines Opponents (Physician Assisted Suicide) ▫Catholic Church (suicide is a mortal sin) ▫American Medical Assoc. (doctors are healers, not killers) Proponents (Physician Aided Death) ▫Compassion and Choices ▫National Death With Dignity Center

5. CHANGING TIMES JACK KEVORKIANBRITTANY MAYNARD

6. CHANGING TIMES Hemlock SocietyCompassion and Choices

7. Legal Landscape

8. United States Supreme Court No 14 th Amendment Due Process Clause liberty interest in choosing physician-facilitated suicide (Washington v. Glucksburg) Bans on physician-facilitated do not violate the 14 th Amendment Equal Protection Clause (Vacco v. Quill)

9. PAS is statutorily illegal (either the act or the supplying of the prescription) Arkansas Georgia Idaho North Dakota Rhode Island

10. PFS is legal Public Initiatives ▫Oregon (1997) ▫Washington (2008) Legislative Intervention ▫Vermont (2013) ▫California (2015) Judicial Interpretation ▫Montana (2009) ▫Note: In 2015, bills were defeated in 25 states

11. Oregon and Washington Oregon Death With Dignity Act Washington Death With Dignity Act

12. California and Vermont California End of Life Option Act Vermont’s Patient Choice and Control at End of Life Act

13. Montana Baxter-physician facilitated suicide is a valid statutory defense to homicide in Montana (possibility of a state ban still exists)

14. In Limbo Hawaii-PAS is not legal but the act is not covered by the homicide statute New Mexico-Morris v. King ▫Dist. Ct.-Statute making PAS a fourth degree felony was unconstl because the right to choose aid in dying is protected by the liberty clause of the state const. ▫App. Ct.-Aid in dying is not a fundamental liberty interest ▫State Sup Ct.-heard case on Oct. 26.

15. The Statutory Provisions

16. The laws permits a ▫Capable ▫Adult ▫Resident ▫Who has been diagnosed with a terminal disease ▫Who makes an informed decision ▫To request in writing a prescription for a lethal dose of medicine Key Provisions

17. Initial request must be in writing signed by the patient in the presence of at least 2 witnesses (one must be disinterested) A second physician must confirm the diagnosis After a 15 day waiting period, patient must make an oral request for the medication Mandated Procedure

18. ETHICAL CONCERNS (Over and Under Inclusive Problem)

19. Disposal People Included but not protected ▫Elderly ▫Physically Disabled ▫Mentally Ill ▫Low-Income ▫People of Color Not Included ▫Minors ▫Non-terminal patients

20. The Elderly May feel a duty to die because they don’t want to be a burden on their families Family members may pressure the elderly person into choosing the medicine The option to doctor shop may leave the elderly vulnerable to abuse At least five of the fifteen deaths in the first year of Oregon ‘s law's operation were of people who had first been turned down by at least one doctor

21. The Physically Disabled Doctors and insurance companies may aggressively encourage the disabled to choose the medication. If the disability requires long-term treatment, the insurance company may cover the cost of PAS but not be willing to cover more expensive options.

22. The Mentally Ill/Depressed In order to be deemed competent to request the medication, counseling is only required if the person is suspected of being clinically depressed or mentally ill. This diagnosis can be made by any doctor and nothing prevents doctor shopping.

23. The Low Income PAS may have unintended consequences for low-income persons. The amount spent on end- of-life care has increased and so the need to ration health care is occurring. In Oregon, an insurance company refused to pay $4000 per month for a low-income woman with advanced lung cancer to get chemo because it didn’t fit their guidelines of appropriate treatment but it offered to pay $50 for lethal prescription drugs to end her life.

24. Low Income and People of Color Due to disparity in health care, low income and people of color tend to receive lower quality preventive care and poor pain management. These factors often place them in situations where they may end up terminally ill. It is not fair to use resources to help those people die and not use resources to help them live longer.

25. Low Income and People of Color Persons in these populations may be considered to be disposal and encouraged to request the medication as the first course of treatment. If we cannot do anything to ensure that they get adequate medical treatment, we probably cannot protect them from being encouraged to self- terminate.

26. Excluded Groups

27. Minors and Persons Who Are Not Terminal A person who is 18 years or younger A person predicted to survive longer than 6 months A person suffering from a progressive, irreversible brain disorder that is not predicted to physically die

28. Thanks Browne Lewis, M.A., J.D., L.L.M. Leon M. and Gloria Plevin Professor of Law Cleveland State University Core Fulbright Scholar, King’s College London