Written Testimony of Katie Glenn, Esq.
Government Affairs Counsel, Americans United for Life
Against H.F. 2152, the “End-of-Life Options Act”
State of Minnesota House of Representatives
Submitted to the Health and Human Services Policy Committee
September 11, 2019
Dear Chairwoman Moran and Members of the Committee:
I serve as Government Affairs Counsel for Americans United for Life (AUL), America’s original and most active organization advocating for life-affirming support and protections for the most vulnerable members of our communities. Established in 1971, AUL has dedicated nearly 50 years to advocating for everyone to be welcomed in life and protected in law. In my practice I specialize in life- and health-related legislation, and I am testifying as an expert in constitutional law generally and in the constitutionality of end of life-related laws specifically. I appreciate the opportunity to provide written testimony against H.F. 2152, which would legalize suicide by medical means in Minnesota.
I have thoroughly reviewed H.F. 2152, and it is my opinion that the Act places already-vulnerable persons at even greater risk, fails to protect the integrity and ethics of the medical profession, and goes against the prevailing consensus that states have a duty to protect life.
Suicide by Physician Places Already-Vulnerable Persons at Greater Risk
Minnesota has a responsibility to protect vulnerable persons—including people living in poverty, elder adults, and those living with disabilities—from abuse, neglect, and coercion. Considering the risk posed to these vulnerable individuals, legalizing suicide can be considered neither a “compassionate” nor an appropriate solution for those who may suffer depression or loss of hope at the end of life.
Indeed, contrary to the prevailing cultural narrative, the reason why people consider seeking assistance in their suicide is neither pain nor fear of pain. In the last 15 years, pain and fear of pain have never been in the top five reasons cited by those seeking assisted suicide in Oregon;1 the latest data from Washington State reveal the same concerns.2 As bioethicist Ezekiel Emanuel has noted, “the main drivers [of those contemplating suicide by physician] are depression, hopelessness, and fear of loss of autonomy and control. . . . . In this light, assisted suicide looks less like a good death in the face of unremitting pain and more like plain old suicide.”3
Emanuel is not alone. Many in the bioethics, legal, and medical fields have raised significant questions regarding the existence of abuses and failures in jurisdictions that have approved prescription suicide, including a lack of reporting and accountability, coercion, and failure to assure the competency of the requesting patient.4 The most vulnerable among us, such as the poor, the elderly, the terminally ill, the disabled, and the depressed, are equally worthy of life and even more in need of equal protection under the law, and state prohibitions on promoting or enabling suicide reflect and reinforce the well-supported policy “that the lives of the terminally ill, disabled and elderly people must be no less valued than the lives of the young and healthy.”5 Speaking to this disparate treatment, Dr. Kevin Fitzpatrick wrote, “When non-disabled people say they despair of their future, suicide prevention is the default service we must provide. Disabled people, by contrast, feel the seductive, easy arm of the few, supposedly trusted medical professionals, around their shoulder; someone who says ‘Well, you’ve done enough. No-one could blame you.’”6
There has been discussion of a “suicide contagion,” or the Werther Effect.7 Empirical evidence shows media coverage of suicide inspires others to commit suicide as well.8 One study, which incorporated statistics on legalized prescriptive suicide, demonstrated that legalizing suicide for “terminal” patients in certain states has led to a rise in overall suicide rates—assisted and unassisted—in those states.9 The study’s key findings show that after accounting for demographic, socioeconomic, and other state-specific factors, suicide by physician is associated with a 6.3% increase in overall suicide rates.10 These effects are even greater for individuals older than 65 years of age—a 14% increase.11 And so suicide prevention experts have criticized assisted-suicide advertising campaigns, writing that a billboard proclaiming “My Life My Death My Choice,” which provided a website address, was “irresponsible and downright dangerous; it is the equivalent of handing a gun to someone who is suicidal.”12
The Supposed Safeguards Are Ineffective in Practice
Despite the so-called “safeguards,” opening the door for suicide via prescriptive means also opens the door to real abuse. For example, the Act requires that the attending health care provider and consulting health care provider be in agreement regarding the patient’s diagnosis and capacity, but neither is required to have any specialization or experience in mental health care.13 Under the Act, the attending health care provider is only required to refer to a mental health provider to determine capacity to make an informed decision, not to treat the underlying distress.14 Thus, the involvement of a mental health care provider under this Act is essentially a rubber stamp to permit the suicide to proceed rather than authentic healthcare aimed at caring for and treating the patient.
In addition, the Act assumes the physicians are able to make the correct diagnosis that a patient has an incurable and irreversible disease which will “result in death within 6 months.” But this fails as a safeguard as terminality is not easy to predict. Current studies have shown “experts put the [misdiagnosis] rate at around 40%,”15 and there have been cases reported where, despite the lack of underlying symptoms, the doctor made an “error”16 which resulted in the individual’s death. Prognoses can be made in error as well, with one study showing at least 17% of patients were misinformed.17 Nicholas Christakis, a Harvard professor of sociology and medicine, agreed “doctors often get terminality wrong in determining eligibility for hospice care,”18 and Arthur Caplan, the director of the Center for Bioethics at the University of Pennsylvania, considers a six month requirement arbitrary.19 Even the Oregon Health Authority admitted, “[t]he question is: should the disease be allowed to take its course, absent further treatment, is the patient likely to die within six months? . . . [Y]ou could also argue that even if the treatment [or] medication could actually cure the disease, and the patient cannot pay for the treatment, then the disease remains incurable.”20
Suicide by Physician Erodes the Integrity and Ethics of the Medical Profession
Prohibitions on physician-enabled suicide also protect the integrity and ethics of the medical profession, including its obligation to serve its patients as healers, as well as to the principles articulated in the Hippocratic Oath to “keep the sick from harm and injustice” and to “refrain from giving anybody a deadly drug if asked for it, nor make a suggestion to this effect.”21 Likewise, the American Medical Association (AMA) does not support suicide by physician, even for individuals facing the end of life. The AMA states that “permitting physicians to engage in assisted suicide would ultimately cause more harm than good. Physician-assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks.”22 In fact, the AMA states the physician must “aggressively respond to the needs of the patients” and “respect patient autonomy [and] provide appropriate comfort care and adequate pain control.”23 Just this summer, the AMA reaffirmed its position against suicide by physician by a vote of 65-35.24
Furthermore, the Act threatens the integrity of the medical profession and the conscience rights of healthcare professionals. Though it allows health care providers to opt out of participating in providing medication to patients for this purpose, it requires that they refer patients to other providers.25 The Act also requires the attending health care provider explain the process of suicide by physician as one of the several treatment options available to a patient under Minnesota law. Thus, a health care provider who is morally or ethically opposed to suicide by physician will still be forced to discuss it alongside authentic healthcare.26 Furthermore, the Act violates the religious freedom rights of faith-based health care facilities by prohibiting them from limiting their employment and contracting to providers who align with the facility’s organizational mission.27 Under the Act, faith-based care facilities can restrict a patient from self-administering the lethal medication on the premises, but they cannot require that a health care provider give medical advice consistent with the mission and theology underpinning the organization. Not only is this a clear conscience violation, but it diverges from decades-old rights of conscience in other aspects of “life care.” This opt out provision is insufficient for providers whose conscience forbids them from participating at all in the premature ending of a life. Referral to a willing physician is still facilitating the outcome, and even more so when a health care provider must spend money on records transferal. A facility with a conscientious objection to suicide by physician—whether moral, ethical, or both—simply cannot be forced to employ providers who advocate for this type of treatment.
This Act harms the medical profession, physicians, and people who may be struggling to process the shock of a difficult diagnosis. It opens the door for physicians to be forced to violate medical ethics, such as the Hippocratic Oath to “do no harm,” as well as their moral convictions or religious beliefs against taking one’s own life or assisting another to end her life. If passed, physicians who object to physician-assisted suicide for ethical, religious, or moral reasons will be forced to choose between violating their conscience or violating the law and potentially losing their medical license. This Act increases the risk that patients will be coerced or pressured into prematurely ending their lives when pitched with assisted suicide as a viable treatment option along with its alleged benefits. Additionally, a physician is prohibited from proceeding with any life-affirming care even for a terminally ill patient until that patient has given informed consent, which under the Act, must include information about physician-assisted suicide.
The Act muddles reporting data and complicates our understanding of medical outcomes. It requires that the cause of death be listed as the underlying terminal illness, not suicide or homicide.28 This skews the numbers downward related to suicide, and it distorts data related to the longevity of life for a person diagnosed with a terminal illness. This reporting requirement makes it impossible to even know how many patients are completing the act of suicide by physician. How can the government and health care providers assess and regulate the safety of this procedure without the ability to understand how frequently it is even occurring?
The U.S. Supreme Court has stated “[t]he State also has an interest in protecting the integrity and ethics of the medical profession.”29 In Justice Antonin Scalia’s dissent to another Supreme Court case involving a ban on the use of controlled substances for physician-assisted suicide, he pointed out: “Virtually every relevant source of authoritative meaning confirms that the phrase ‘legitimate medical purpose’ does not include intentionally assisting suicide. ‘Medicine’ refers to ‘[t]he science and art dealing with the prevention, cure, or alleviation of disease’ . . . [T]he AMA has determined that ‘[p]hysician-assisted suicide is fundamentally incompatible with the physician’s role as healer.’”30
The Majority of States Affirmatively Prohibit Medicalized Suicide
Currently, the overwhelming majority of states—at least 39 states—affirmatively prohibit assisted suicide and impose criminal penalties on anyone who helps another person end his or her life. And since Oregon first legalized the practice in 1996, “about 200 assisted-suicide bills have failed in more than half the states,” and more states have moved to ban the practice than have decided it was worth the risk.31 In Washington v. Glucksberg, the United States Supreme Court summed up the consensus of the states: “In almost every State—indeed, in almost every western democracy—it is a crime to assist a suicide. The States’ assisted-suicide bans are not innovations. Rather, they are longstanding expressions of the States’ commitment to the protection and preservation of all human life.”32
This longstanding consensus among the vast majority of states is unsurprising when one considers, as the Court did, that “opposition to and condemnation of suicide—and, therefore, of assisting suicide—are consistent and enduring themes of our philosophical, legal and cultural heritages.”33 Indeed, over twenty years ago, the Court in Glucksberg held there is no fundamental right to assisted suicide in the U.S. Constitution, finding instead that there exists for the states “an ‘unqualified interest in the preservation of human life[,]’ . . . in preventing suicide, and in studying, identifying, and treating its causes.”34
Indeed, Minnesota criminalized assisted suicide decades ago; it is unlawful to “intentionally advise, encourage, or assist another in taking the other’s own life.” 35 That law was upheld by the lower courts and petition for review was denied by the Supreme Court of the United States in 2017.36
Minnesota should reject H.F. 2152 and continue to uphold its duty to protect the lives of all its citizens—especially vulnerable individuals such as the ill, elderly, and disabled—and maintain the integrity and ethics of the medical profession. Thank you.
Katie Glenn, Esq.
Government Affairs Counsel
Americans United for Life