Did California Dodge a “Right-to-Die” Bullet?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Mark Komrad

Psychiatrists, Dr's Mark Komrad and Annette Hanson, Ronald Pies and Cynthia Gepert, wrote a commentary on the recent attempted expansion of California's assisted suicide law that was published by the Psychiatric Times.

Komrad et al, express their concerns that, even though SB 1196 was pulled by its sponsor that it represents the strongest example of slippage with the US assisted suicide laws to a far more permissive position. They state:

As opponents of PAS/E, we often hear proponents claim that the “slippery slope” argument is merely hypothetical—an alarmist bogeyman used to scare away supporters of PAS/E. We also hear that, even if the slippery slope metaphor applies in foreign countries, “It would never happen here” in the US. We respectfully disagree. For while the angle of the slope is considerably greater in Canada and the Benelux countries than in the US, we find troubling signs of slippage here at home.

Annette Hanson

Komrad et al ask if SB 1196 is: A Harbinger of Things to Come? They explain:

California Senate Bill 1196 was introduced by Senator Catherine Blakespeare and represented a radical departure from existing California law.

Among its other provisions, SB 1196 proposed the following changes:

• It eliminated the California residency requirement for PAS.
• It replaced the criterion of “terminal disease” with “grievous and irremediable medical condition” that is “causing the individual to endure physical or psychological suffering… that is intolerable to the individual and cannot be relieved in a manner the individual deems acceptable.”
• It changed the criterion of the disease from “expected to result in death within 6 months” to “it is reasonably foreseeable that the condition will become the individual’s natural cause of death.” (This is identical to the vague language invented in Canada’s 2016 C-14 bill, which was never statutorily defined).
• It included a diagnosis of early to mid-stage dementia in the definition of a “grievous and irremediable medical condition.”
• It expanded the definition of “mental health specialist” to include neurologists and omitted any requirement for an evaluation by a psychiatrist or psychologist.
• It authorized “the self-administration of an aid-in-dying drug through intravenous injection.” This would have allowed health care practitioners to facilitate death by inserting an IV line—not merely writing a prescription, or dispensing and preparing the lethal drugs.

Ronald Pies

Additionally, SB 1196 contained language that would have turned these practices into a quasi-research protocol by requiring the prescribing physician to report the type of lethal medications prescribed; the time from drug ingestion/administration to death; and any observed complications.

Komrad et al explain how assisted suicide laws are "stretching the boundaries." They explain: 

This extraordinary attempt to expand California's law illustrates what many states may expect if laws permitting PAS (or euthanasia) are adopted. Indeed, contrary to the “It can’t happen here” argument, we have already seen examples of slippage in several US states. These expansionary rules may be categorized as modifications of (1) waiting periods for PAS; (2) conditions of PAS eligibility; or (3) expansion of authority to carry out PAS; or some combination of these modifications.

For example,

• In New Mexico, advanced practice nurses and physician assistants are now allowed to carry out assisted suicide, and the waiting period between evaluation and lethal prescription has shrunk from 15 days to 48 hours. In addition, “a provider can waive the 48-hour waiting period if the patient is unlikely to survive the waiting period.”
• In Oregon, the state residency requirement has been eliminated, and if the patient’s death is predicted to be within 15 days, the lethal drugs may be prescribed on the same day as evaluation of the patient. Notably, “Prescriptions for lethal doses of medication in Oregon increased by nearly 30% in 2023, the same year an amendment to the state's Death with Dignity Act removed the in-state residency requirement for patients…”
• In 2022, Vermont bill S.74 was signed into law, allowing patients to request the lethal prescription using telemedicine. S.74 also got rid of the final 48-hour waiting period. Then, in 2023, Vermont removed the residency requirement from Act 39, the Patient Choice at End of Life law.
• In Washington State, as of 2023, physician assistants and advanced registered nurse practitioners are now permitted to prescribe the lethal drugs, and mental competency can be evaluated by any licensed ‘mental health counselor.’ If death is deemed “imminent,” the lethal prescription can be written the same day as the eligibility evaluation.

Cynthia Geppert

As expansive as these recent modifications are, they pale in comparison to the radical changes proposed in SB 1196.

Komrad et al comment on the extension of assisted suicide to people with Anorexia Nervosa. They write:

In March of 2022, the Colorado Sun ran the following headline: “Denver doctor helped patients with severe anorexia obtain aid-in-dying medication, spurring national ethics debate.”

The article explains that Dr Jennifer Gaudiani assisted the suicides of three people with eating disorders. Komrad and Hanson explain:

The third patient—Alyssa B—was actually a coauthor of the paper with Dr Gaudiani. According to the published paper,18 “Dr. G prescribed the MAID medications about 6 weeks after Alyssa entered hospice care.”

The Gaudiani et al paper is notable in acknowledging that: 

“Alyssa had not completed a full residential eating disorder program; never fully restored weight; never tried newer psychedelic options such as ketamine, psilocybin, or MDMA; and hadn’t had a feeding tube. Dr. G acknowledged that all but the feeding tube might ordinarily be undertaken prior to someone’s seeking end of life care for AN. Yet, [Alyssa] had been suffering for so long, and despite many conversations about all these treatment possibilities, Alyssa would not consent to any of them. Therefore, given her clarity of understanding around these issues and her sense that she could not fight anymore, everyone had to accept that they weren’t meaningful options.”

Not surprisingly, the published paper and its rationale were vociferously criticized by many in the psychiatric community. For example, Dr Angela Guarda—the director of the eating disorders program at Johns Hopkins—is quoted as saying that using aid-in-dying medication for anorexia patients is “alarming” and “fraught with problems.” This is partly because “…it is impossible to disentangle this request [for PAS] from the effects of the disorder on reasoning, and especially so in the chronically ill, demoralized patient who is likely to feel a failure.”

Komrad et al explain how the three assisted suicide deaths of people with eating disorders is another clear sign of a practical slippery slope with US assisted suicide laws. 

They conclude their article by stating:

In our view, the phenomenon of the slippery slope is, in large part, the expectable consequence of “normalizing” or naturalizing the physician’s direct or indirect killing of the patient; ie, via euthanasia or PAS, respectively. The more widely these acts are performed, the easier it becomes to mischaracterize them as forms of “medical care.” This is epitomized in the obfuscating euphemism, “medical aid in dying.” As the American College of Physicians has stated:

“Terms for physician-assisted suicide, such as aid in dying, medical aid in dying, physician-assisted death, and hastened death, lump categories of action together, obscuring the ethics of what is at stake and making meaningful debate difficult.”

In truth, assisted suicide does not “aid” the dying process—it terminates dying by terminating the patient.

By the same token, the more PAS and euthanasia are viewed as medical care, the easier it becomes to enlarge the eligibility criteria to encompass almost anyone who feels they are “suffering.” Then the slide down the slope can accelerate, from terminal conditions to chronic conditions (such as mental illness), as is happening in our culturally and geographically adjacent neighbor, Canada. That opens the path for the next drift in the evolving ethos—transforming one’s “opportunity” to seek these lethal procedures into the virtue of relieving loved ones from the burden of their condition.

Finally, we believe it essential that the APA maintain its ethical opposition to PAS/E, consistent with the American Medical Association Code of Ethics.4 Doing otherwise will create a schism between the APA and the AMA. Indeed, we hope that as our colleagues consider these issues at the APA meeting, they bear in mind the teaching from medical ethicist Dr Leon Kass: “We must care for the dying, not make them dead.”

It is my belief that SB 1196 is the direction of the assisted suicide lobby, not just an experimental bill to gage a reaction.