THREE years ago John Radcliffe, a jovial retired lobbyist in Hawaii, was diagnosed with terminal stage four colon and liver cancer. He has since undergone 60 rounds of chemotherapy but doctors suspect he has just six more months to live. His illness often leaves him feeling exhausted but, undeterred, he has spent the past few years pushing to pass one last bill: Hawaii’s “Our Care, Our Choice Act”, which allows doctors to assist terminally ill patients who wish to die. Earlier this month, as Mr Radcliffe beamed behind him in a colourful lei, Hawaii’s governor signed the bill into law making Hawaii the seventh American jurisdiction to approve an assisted-dying law.
Like the laws in California, Washington, Vermont, Colorado and Washington, DC, Hawaii’s law is modelled on legislation in Oregon, which was the first state to allow assisted dying, in 1997. It permits an adult, who two doctors agree has less than six months to live and is mentally sound, to request lethal medication. The most commonly used drug is secobarbital, a barbiturate that induces sleep and eventually death by slowing the brain and nervous system. It is usually prescribed in the form of about 100 capsules that must be individually opened and mixed into liquid—a process advocates say averts accidental overdoses. The patient must take the medication themselves, without aid, but they can choose when and where to do so. Death with Dignity, an Oregon-based pressure group, estimates that 90% of the recipients of this service end their lives at home.
Legislatures in 24 other states are considering similar bills this year. Most will flounder. In 2017, 27 states debated assisted dying. None approved it. Still, the right-to-die movement seems likely to gather momentum. Between 1997 and 2008, Oregon was the only state that allowed doctors to let some patients hasten their deaths. In the decade since, six other jurisdictions have legalised assisted dying, either through legislation or ballot initiatives. Advocates are hopeful that Nevada, New Jersey and Massachusetts might soon follow.
A few factors make such laws likely to continue spreading. The first is public support. In 1947, when Gallup, a polling group, first began conducting surveys on the issue, 37% of Americans thought a “doctor should be allowed to end a terminally ill patient’s life by painless means” if requested by the patient. Since 1990, between 64% and 75% have expressed support for doctor-assisted dying (see chart). The remaining objections are concentrated among the religiously observant, though Gallup finds that a narrow majority of weekly churchgoers support assisted dying.
Doctors have become more accepting of the notion too. An ethics report published by Medscape, a medical news website, in December 2016 found that 57% of doctors surveyed believed doctor-assisted death should be available to the terminally ill, up from 46% who thought so in 2010. While the American Medical Association, America’s largest association of physicians, remains opposed to the practice on the grounds that “physician-assisted suicide is fundamentally incompatible with the physician’s role as a healer,” some state medical groups have dropped their opposition to the procedure.
Kim Callinan of Compassion & Choices, a pressure group, believes there are several reasons for the growth in support. Since the first Death with Dignity Act was implemented in Oregon, there has been no evidence of misuse or abuse. In the past few years several high-profile cases have drawn attention to the issue. Perhaps the best known is that of Brittany Maynard, a young Californian woman with terminal brain cancer, who fervently advocated for right-to-die laws until she ended her life in November 2014 in Oregon. The third factor is the ageing of the baby-boomer generation, which is America’s most populous. “They’re starting to see their parents experience horrible deaths, and are beginning to contemplate their own ends,” Ms Callinan says.
But even in places that have approved assisted-dying laws, accessing it can be problematic. The Washington, DC, Council approved an assisted-dying ordinance in 2016. But since the law was implemented in July 2017, not a single patient has been able to take advantage of it. Peg Sandeen, the executive director of Death with Dignity, the Oregon-based organisation, explains that until recently the law was in jeopardy. A panel of congresspeople sought to include an amendment in the recent omnibus funding bill that would have repealed it. That effort flopped, which advocates hope will assuage DC doctors’ worries. Second, the DC law has more stringent administrative requirements than those in other American jurisdictions. The health department there requires that doctors register on a database before providing medical aid-in-dying. Requests remain fairly rare—only 218 people requested prescriptions in Oregon in 2017 and 111 people ended their lives in California in the first six months after the law came into force—so some doctors might not think the extra bureaucracy worth it.
Mary Klein, a retired journalist who lives in Washington, DC, and has terminal ovarian cancer, said she has sought medical aid-in-dying from five different doctors to no avail. A few have told her that they think palliative care is sufficient. Ms Klein, who watched her stepmother die in a hospital while receiving pain medicine that made her incoherent, disagrees. “No one wants to be in intolerable pain – but just as important is self-determination. I want to die peacefully in my home surrounded by loved ones. I want to be lucid when I say goodbye to my wife.”