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Viewpoint |

The Challenge of New Legislation on Physician-Assisted Death

Linda Ganzini, MD, MPH1; Anthony L. Back, MD2
[+] Author Affiliations
1Department of Psychiatry, Oregon Health & Science University & VA Portland Health Care System, Portland
2Department of Medicine, University of Washington, Seattle
JAMA Intern Med. 2016;176(4):427-428. doi:10.1001/jamainternmed.2016.0047.
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This Viewpoint discusses the need for international cooperation in deciding how professional societies, academic medical centers, medical groups, and health care systems can best integrate physician-assisted death into their practices.

By the end of 2016, more than 80 million people in the United States and Canada will live in a jurisdiction allowing physician-assisted death. As such, this practice can no longer be considered a quirky experiment in a few states. The North American experience with physician-assisted death began in 1994, when voters in Oregon approved a ballot measure, the Death With Dignity Act, allowing a physician to prescribe a lethal dose of a medication that a patient voluntarily self-administers. Oregon stood alone for 14 years until Washington (2008), Vermont (2013), and now California (2015) approved similar laws. As of January 2016, the effective date of the California law, known as the End of Life Option Act, is uncertain. These laws are in general very similar, with safeguards that include requirements for a waiting period and that eligible patients be mentally competent, not mentally ill, and have a life expectancy of less than 6 months. In 2009, the Montana Supreme Court removed prohibitions against physician-assisted death for competent patients. There are no reporting requirements in Montana, so little is known about the actual practice of physician-assisted death in that state. In 2015, the Canadian Supreme Court unanimously reversed a federal law that prohibited physician-assisted death and gave the government until June 2016 to establish mechanisms for access to such assistance.1,2

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Equity Challenges in Physician Assisted Death
Posted on April 21, 2016
Esha Ray Chaudhuri PhD
Conflict of Interest: None Declared
Although the focus of the Comment is on challenges of the New Legislation about Physician Assisted Death, and questioning its equity impact, I am in full agreement with Linda Ganzini and Anthony L Back’s Viewpoint (1) that within the setting of national standards and effective mechanisms for protocol enforcement, voluntary euthanasia -considered as a healthcare consumer right and therefore as an obligation of healthcare providers –can be revisited for a shift in policy.

The authors’ recommendations about the importance of expanding access to palliative care , high quality communication skills training for physicians, and comprehensive public reporting systems-which emerge as being central to addressing the “Challenges” of the New Legislation -are largely efficiency measures designed for a specific population who voluntarily seek physicians assistance to end their lives and sufferings.

In cases of the continuing “invisible” practice of passive euthanasia, as Unilateral Withholding practices are essentially acknowledged to be, physicians’ unilateral decisions intentionally override the critical criteria of patients’ Voluntary choice and as such, pose perilous risks to the New Legislation by making equity “slopes “ more “slippery”. Research studies on medical best practices, biomedical ethics as well as reviews of legal challenges for controversial end of life (EOL) care practices such as Withholding or Withdrawing , identify a growing concern for inequities in systemic perceptions of legitimacy of patients’ EOL choice, including a pattern of denial for choice of care goals based on patients’ personal values about sustenance of life as opposed to their “right to die”(.2) . There is a serious disconnect in generic perception of competent adult patients’ voluntary choice for attempting ordinary life sustaining intervention as “ill informed” or “futile” and professed policy commitment to patients’ autonomy. Recognition of variations in patients EOL choice (3 ), may be particularly important in encountering the pervasive perception biases that contribute to “limited and unclear understanding” of diverse requests of patients, as noted by Ganzini and Black and also mentioned in the landmark report on End of Life Decision making in Canada (4).The importance of the links between the legal, ethical, medical and most importantly the social determinants of End of Life care policies is often absent from analysis of the efficiency measures particularly from standpoint of a pluralist patient population. The equity analysis calls for a comprehensive and effective understanding of these links.


1.Ganzini,Linda ;Anthony L.Black. The Challenge of New Legislation on Physician-Assisted Death JAMA Intern Med. 2016;176(4):427-428

2.Judgments of the Supreme Court of Canada. Cuthbertson V,Rasouli.2013 ; Court of Queen’s Bench,Manitoba. Golubchuk V Salvation Army Grace Hospital ,2008

3.Esha Ray Chaudhuri. Cultural Variations in Serious Illness Care Goals. Comment posted in JAMA Intern Med. 2014; 174 (12)

4.The Royal Society of Canada. Expert Panel Report . End-of-Life Decision-Making in Canada:, Nov 2011
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