Barrier to medical aid in dying can be state line
Residency rules add to complex process for terminal patients
Five years ago, Dr. Nicholas Gideonse spoke with an older man who had received a terminal cancer diagnosis and was hoping to use Oregon’s medical aid-in-dying law.
Oregon’s Death With Dignity Act, in effect since 1997, permits doctors, after a complex process of requests and waiting periods, to prescribe lethal medication for dying patients to self-ingest.
The nonprofit group End of Life Choices Oregon had referred the man to Gideonse, a primary care doctor at Oregon Health & Science University and a hospice medical director, who had already helped many patients use the law.
But this time he could not. “I’m really sorry,” he told the man on the phone. “I’m not going to be able to help you with this.” Oregon’s law — and all the laws that permit medical aid in dying in 10 states and Washington, D.C. — has residency requirements. This man would have qualified — except for that fact he lived in nearby Washington state.
The patient’s response, Gideonse recalled, was “stunned silence, deep disappointment.” A number of Gideonse’s primary care patients drive 20 to 30 minutes across the Washington border to his office in Portland. There, he can offer them any medical service he is qualified to provide — except that one — without proof of residency. And although Washington has its own aid-in-dying law, its southwestern region has few providers who can help patients use it.
Gideonse, backed by pro bono lawyers and Compassion & Choices, an advocacy group for expanding end-of-life options, recently filed a federal lawsuit claiming that the residency requirement for Oregon’s aid-in-dying law is unconstitutional. “I realized how important this could be for patients seeking access,” he said.
The lawsuit is one of several legal and legislative efforts around the country to reduce the requirements that patients must contend with in order to receive aid in dying. In some states, lawmakers have already broadened the types of health care providers that can participate, or have shortened waiting periods or allowed waivers.
“I think of it as
MAID 2.0,” said Thaddeus Pope, an end-of-life bioethicist at Mitchell Hamline School of Law in St. Paul, Minnesota, who tracks such actions, referring to the acronym for medical aid in dying. “We found out there’s an access problem.” He added, “We set all these safeguards and eligibility requirements, and they locked a lot of people out.”
Oregon led the shift in easing access, amending its law in 2019. The state previously required patients to make two verbal requests for life-ending medication, at least 15 days apart, to ensure that they had not changed their minds. Now, if the patient is unlikely to survive that long, their doctor can waive the 15-day waiting period.
“Fifteen days is everything when you are suffering,” said Kim Callinan, president and CEO of Compassion & Choices, which supported the change. “People who are eligible for the law are hitting roadblocks and barriers.”
A 2018 study from the Kaiser Permanente health system in Southern California showed that about one-third of qualifying patients died before they could complete the process.
New Mexico, which in June became the most recent state to legalize medical aid in dying, has adopted a markedly less restrictive approach than other states. The largely rural state is the first to allow not only doctors but also advanced practice registered nurses and physician assistants to help determine eligibility and write prescriptions for lethal medication.
Although a doctor must also affirm that a patient is terminally ill, New Mexico patients can skip that step if they have already enrolled in hospice. The patient need only make one written request, rather than two or more requests, as other states require. A 48-hour waiting period between when the prescription is written and when it is filled can be waived.
California has simplified its 2016 law as well. In October, Gov. Gavin Newsom signed legislation that, starting in January, reduces the 15-day wait between verbal requests to 48 hours and eliminates the requirement for a third written “attestation.”
Similar bills died during the most recent legislative sessions in Hawaii, Washington and Vermont, but will be reintroduced, Callinan said. And in many states — including Delaware, Indiana, North Carolina, Virginia, Pennsylvania and Arizona — new aid-in-dying bills, if passed, will ease requirements for patients or expand the kinds of providers who may participate.
On the legal front, the Oregon lawsuit filed by Gideonse argues that residency requirements for aid in dying violate two sections of the U.S. Constitution, one barring state laws that limit the ability of a nonresident to access medical care and one prohibiting state laws that burden interstate commerce.
“This is the only medical procedure we can think of that is limited by someone’s ZIP code,” said Kevin Diaz, the chief legal advocacy officer at Compassion & Choices.
Catholic organizations, anti-abortion advocates and some disability groups continue to oppose aid in dying. The California Catholic Conference, the church’s public policy organization, for example, argued in June that liberalizing the state’s law “puts patients at risk of abuse and the early and unwillful termination of life.”
But polls regularly report broad public support. Last year, Gallup found that 74% of respondents agreed that doctors should be allowed to end patients’ lives “by some painless means” if they and their families request it.
Liberalizing the laws will likely increase participation, Pope predicts.
“We know from evidence around the world that if you reduce the waiting period, or allow waivers in certain cases, it materially expands access,” he said.
Experts do not expect a major surge, however. Even in states where the practice has been legal for years, aid in dying accounts for few deaths, a fraction of 1%. Of those who successfully navigate the process, moreover, about one-third do not use the drugs and instead die of their diseases.
Still, should Gideonse prevail in his lawsuit and a likely appeal, residency requirements in other regions might also start to fall. It is an outcome that would please Gideonse. “This is an action in support of a needed and very important service,” he said. “I’m optimistic.”