How America abandoned its assisted suicide "safeguards"

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Alexander Raikin

Alexander Raikin wrote an excellent article: How America abandoned its suicide safeguards which explains how the US states that have legalized assisted suicide abandoned the "safeguards" in their assisted suicide laws. I have written several articles on this topic especially since nearly every assisted suicide law in America, once passed, was later expanded. Raikin explains:

In 2020, Jane, a 29-year-old Colorado woman with eating disorders, was “provided with lethal drugs … in the midst of a mental-health crisis”, according to a lawsuit filed this year by the Institute for Patients’ Rights, an advocacy group seeking to overturn Colorado’s assisted-suicide program. Jane qualified for assisted suicide, the lawsuit contends, yet she was discharged from a hospice because she no longer qualified for hospice care, and her hospice considered her no longer competent to consent to medical treatments. So how could she have consented to suicide-by-doctor?

Jane was fortunate: her parents successfully sued for guardianship, and a court ordered the medication to be destroyed. Jane “went on to recover from all of it, including her anorexia”, according to Matt Vallière, the executive director of the Institute for Patients’ Rights. Jane found work as an occupational therapist, went on vacation, and even purchased a home. Although she ultimately died two years later of complications from her history of eating disorders, she’d had an opportunity to “live her best life”, Vallière says. That any medical professional decided that Jane qualified for assisted suicide, he claims, was “absurd”.

Raikin states that Jane’s case isn’t unusual and violations of assisted-suicide laws are rampant with no known suspensions or revocations of clinician licenses, even when patients were endangered. Raikin explains how these laws are being violated:

Much of the issue is oversight. In each of the 11 states that have implemented suicide-by-doctor, regulations require clinicians to submit compliance forms, typically within days of a patient’s death. These forms document that the patient expressly consented to die through assisted suicide, and that the clinicians followed all necessary legal safeguards and eligibility criteria, including affirming that the patient is terminally ill and of sound mind.

Failure to submit this documentation isn’t just a statutory offense. Medical providers and pharmacists who fail to “make a good-faith effort to file required documentation in a complete and timely manner”, as Washington state law instructs, risk losing“immunity protection” for the criminal act of assisting someone’s suicide. Yet a Department of Health report found that physicians improperly reported compliance for a third of all assisted suicide deaths in the Evergreen State. Indeed, Washington is missing 515 compliance forms entirely for the period between 2009 to 2023, according to my calculations based on annual reports, and is also short of 293 “written request” documents that patients are required to sign attesting that they wish to die by suicide. In Colorado, my calculations find that almost 1,800 compliance forms have remained missing since 2017.

The actual number of assisted suicide deaths is unknown. Raikin writes:

States can’t answer the most basic question: how many physician-assisted suicides have been facilitated by clinicians in America? Across Colorado and California, state authorities have no record of the type of “aid-in-dying drugs” that were prescribed to more than 1,000 patients, according to my analysis of state reports, including the California End of Life Option Act 2024 Data Report. In Oregon, the health authority has records on 376 assisted suicides completed in 2024, but for another 178 cases in which medications were prescribed, authorities don’t know if the patient died by ingesting the drugs, or even died at all.

Washington State has decided to stop publishing the assisted suicide data.

In 2022, Washington state announced that its Department of Health is diverting “all available funding” for its assisted-suicide compliance-review program to “data entry of submitted forms”, due to lack of funding from the state. Data entry is commendable. But by law, the state is also required to “review” reporting compliance and issue an annual report. Instead, this summer, a pop-up appeared on the department’s website: “Important Note: Due to funding cuts, the Death with Dignity Program at the Department of Health is suspended. … A 2024 annual statistical report will not be released.”

Washington state’s decision surprised even assisted-suicide clinicians. Jessica Kaan, the medical director for End of Life Washington, an institution which facilitates assisted suicides in the state, warned on a forum for providers that “no one will even be monitoring or responding to emails or phone calls that come into the DOH [Department of Health] about the DWD [Dying With Dignity] program”. Kaan called it “a grim situation”. After this push back, the state announced that it will release the 2024 report after all — but it will be the last one ever to be released.

Raikin then explains that New Mexico does not publish an annual report, even though the assisted suicide law requires an annual report. States are also removing the "safeguards" in the law. Raikin explains:

This systematic disregard of safeguards is happening as the process is being fast-tracked: states are removing requirements that applicants reside in state; allowing less-credentialed providers, such as social workers, nurses, and physician associates,to perform assessments instead of psychiatrists and psychologists; and reducing minimum waiting periods. In Oregon, which waived waiting periods in 2020,clinicians have reported in Oregon’s annual Death with Dignity Act report that assisted suicides routinely occur on the same or next day the patient makes there quest. Since in some cases it takes up to five days for a patient to die from ingesting the death cocktail, it is possible that it will take a patient longer to die than to receive lethal prescriptions.

The proportion of vulnerable persons dying by assisted suicide has also increased. Raikin writes:

The proportion of deaths of vulnerable patients has also increased by magnitudes. In the first year of Washington state’s program, 16% of patients mentioned “the physical or emotional burden on family, friends, or caregivers” as a reason for their decision to die, and 2% were concerned about “the financial cost of treating or prolonging the patient’s terminal condition”. By 2023, according to the state’s reporting, the number concerned with “feeling like a burden” jumped to half of all assisted-suicide deaths, and a 10th were concerned about “financial implications of treatment”.

A similar trend is unfolding in Oregon. In 2009, the first year that the program was available, no patients told their assisted-suicide clinician that they were choosing to die because of financial concerns, and only 12% felt like a burden. By 2024, the state’s reporting revealed that it was 9% and 42% of all assisted suicide deaths, respectively. No other states even report this data. The “attending physician follow-up form” in California, which records patient concerns that contribute to the choice of “aid-in-dying”, doesn’t have “financial concerns” or “feeling like a burden” on its otherwise identical menu of options.

Compliance with the law from physicians and the government is lacking. Raikin interviewed Craig New who overseas the assisted suicide program in Oregon. Raikin reports:

Craig New, who told me on the telephone that he’s the sole employee of the Oregon Health Authority responsible for monitoring compliance reporting, says that “ultimately the things usually get resolved because we bug them until they finally send in the paperwork”,but even so, his office has reported around a dozen physicians to the Oregon Medical Board for violations of compliance reporting. Thanks to privacy laws regarding medical licensing, it is impossible to know whether the reported physicians faced repercussions, but my review of the Oregon Medical Board’s investigations reveals that few offenses are prosecuted.

Raikin reports that Dr Rose Jeanine Kenny, in Oregon, was reprimanded by the Oregon Medical Board for contravening the assisted suicide law:

One example is Rose Jeannine Kenny, a family doctor, who in 2016 was sentenced to five years probation by the Oregon Medical Board for dozens of alleged prescription violations. Later the board received “credible information” that Kenny may have again violated the same provisions she was previously reprimanded for, and may possibly have committed “violations of the Oregon Death with Dignity Act”, such as failure to ensure consent, follow the rules of written and oral assisted suicide requests, abide by the minimum waiting period, and file compliance records. Kenny once again kept her license, this time by agreeing to “participate in all physician steps” for 10 more assisted suicides, supervised by a mentoring physician from Compassion & Choices — the largest lobbying group for assisted suicide in the United States. (UnHerd was unable to reach Dr. Kenny at any of the medical practices with which she is associated online.)

Raikin states that no researchers or law enforcement are allowed to systematically review the assisted suicide records. He then tells the story of a person in Maryland with a eating distorder:

Recent court proceedings in Maryland eerily echo the lawsuit regarding Jane. Angela Guarda, the director of the Eating Disorders Program at Johns Hopkins Hospital, testified that she was contacted by an ex-patient of Jennifer Gaudiani, the physician who coined the term “terminal anorexia”, and who has prescribed assisted-suicide medication to at least one patient. The concept of terminal anorexia was meant to apply only to patients over age 30; for younger patients, Gaudiani stressed in a paper for the Journal of Eating Disorders that “every effort should be made to promote full recovery and continuation of life”.

The ex-patient reported that her assisted-suicide assessor told her “she would ‘make an exception’ for me and ‘allow’ me to die”. The patient reported feeling coerced. She eventually weaned herself off morphine and hospice drugs and, 18 months later, reports that she’s doing well, with a job, a group of friends and a new puppy.

Raikin ends the article by stating:

Patients like these, who need hope the most, are facing much more than their illnesses. They also confront an assisted-suicide regime that blatantly and routinely violates the legal safeguards that were meant to ensure their protection from a death they might not want.

Further articles on this topic:

• Assisted suicide lobby launches court case to force Colorado to permit suicide tourism (Link). 
• The push to legalize and extend assisted suicide in America (Link).
• Oregon 2024 assisted suicide report (Link). 
• Death by assisted suicide is not what you think it is (Link).  
• Assisted suicide laws, once passed will inevitably expand (Link). 
• New York assisted suicide bill is a "bait and switch" (Link). 
• Oregon bill would expand assisted suicide again (Link).
  

As an Anorexic, I'd have longed for assisted dying.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Britain is debating an assisted suicide bill sponsored by Kim Leadbeater (MP).

The Committee that is examining the assisted suicide bill is stacked with pro-assisted suicide members. The committee has debated multiple proposed amendments to the legislation and yet all of the amendments that would tighten the bill have been rejected.

An article by Hadley Freeman that was published in The Times on March 2, 2025 looks at the issue of assisted suicide for people with Anorexia. According to Freeman, Leadbeater rejected the proposal in this manner.

One suggested amendment that would have protected anorexics was that a person can’t qualify for assisted death because they have stopped eating and drinking; Leadbeater rejected that, referring to a woman with mouth cancer who had her tongue removed and starved to death. “We have to be careful not to dismiss those cases because they are real stories of real human beings,” she said.

In response Freeman tells her story and the story of a friend who struggled with anorexia.

Here’s another real story of a real human being. When I was 15, I made a new friend. Her name was Nikki Hughes and she was a talented artist, kind and funny. She was also anorexic, and we met because we were admitted to an eating disorders ward on the same day, and that, she said, bonded us for life. I don’t know what doctors made of Nikki, but I do know what they made of me, 15 and on my fifth hospital admission for anorexia. One told my mother to prepare for the very real chance that I would die. That sounded — to my nutrients-starved, illness-addled brain — great, because it confirmed I was good at anorexia.

Nikki was different. She talked about the art she would make when she recovered and would tell me off when she caught me hiding food. Two years later, when I was recovering and back at school, I opened the newspaper and there was a photo of Nikki: she had died. The hospital she was in at the time was told it could not “override her wishes” to starve herself to death and it would be assault if it tried to save her life with a feeding tube.

Freeman continues by explaining anorexia:

Anorexia is complicated: it’s a mental illness that leads to physical complications, which exacerbate the mental ones, and so on. Even more complicated, the more ill a person becomes, the more they resist treatment (eating, in other words) and the more they want to die. Offering an anorexic assisted death is like offering her liposuction: her desire for it is a symptom of her illness.

Right-to-die campaigners love to talk about autonomy, but such terms are meaningless when it comes to women whose minds are crazed by starvation. (Danny) Kruger pointed out last week that increasing numbers of anorexics are being classified as “terminal” in the NHS and given “palliative care”, which the Royal College of Psychiatrists has described as “troubling”.

Freeman further explains her concerns:

As Nikki and I learnt, it is impossible, even for doctors, to predict outcomes. The patient most determined to starve herself into the ether can recover. As my psychiatrist 30 years ago told me, there’s always hope.

Freeman explains that the assisted suicide bill excludes assisted suicide for people with mental illness but anorexia also leads to physical conditions. She writes:

Some believe that the bill excludes those with mental illness. In fact, it excludes those who are terminally ill “only” because of mental illness — anorexia can lead to physical problems, and these can qualify a person for assisted death. Others say only a tiny number of anorexia patients could qualify. But what number is acceptable? Anorexics are already gaining access to assisted death in Colorado, California and Oregon. One consultant said she could foresee a time when “20 to 30 patients with anorexia access assisted dying in this country every year, because of the contagion effect”.

Freeman states that amending the assisted suicide bill was necessary but there was a "religious fervour" in the committee room among "right-to-die" campaigners to push the bill through.

Freeman concludes her article by stating:

It is impossible for most people to comprehend the mind of an anorexic, which hisses that death is preferable to eating. Which is why it is unforgivable that MPs decided not to get hung up on those who do.

More articles on this topic:

• Proposed assisted dying bill fails public safety test (Link).
• Netherlands woman dies by euthanasia based on anorexia (Link).
• Landmark study: Assisted death for eating disorders (Link).
• At least 60 people with eating disorders euthanized or assisted in suicide since 2012 (Link).
• ANAD clarifies that Anorexia Nervosa is not a terminal condition (Link)
• When I was Anorexic I would have chosen assisted suicide (Link).
• Psychiatrist: Anorexia does not justify Aid in Dying (Link).
• Anorexia is not a terminal condition (Link).

 

Proposed UK Assisted Dying Bill Fails Public Safety Test

This letter was published in the British Medical Journal.

Dear Editor,

As the UK Parliament prepares to debate assisted dying, its impact on those with mental health conditions, particularly eating disorders, must be urgently considered. If legalised, the proposed bill may enable patients with treatable eating disorders who have life-threatening malnutrition and/or feel suicidal to qualify for assisted death. Looi (1) highlights global expansion in assisted dying laws, yet gaps in safeguarding vulnerable groups remain.

Research suggests assisted dying laws have already led to preventable deaths of young people with eating disorders in multiple countries (2). At least 60 individuals with eating disorders have died through physician-assisted death, including in jurisdictions limiting the practice to terminal conditions. Of these, one-third involved women under 30. These deaths raise profound ethical concerns, as many patients were severely depressed or suicidal when deemed eligible.

These patients did not have concurrent terminal illnesses. Rather, clinicians asserted their eating disorders were “untreatable,” offering limited substantiating evidence. Some practitioners suggested patients had “terminal anorexia,” a term not recognised by any medical authority (3). Downs et al. (4) described it as a “nosological free-for-all,” highlighting the danger of inventing new illness classifications to justify ending vulnerable lives under the guise of medical treatment. Empirical efforts to validate terminal anorexia have raised significant questions about its validity (5). Anorexia nervosa is not a terminal condition; almost all the medical complications of eating disorders are reversible with nutrition and weight restoration (6).

The proposed bill aims to restrict eligibility to terminal illness — in practice, this safeguard is porous. In Oregon US, officials interpret “terminal illness” as any condition expected to cause death within six months if untreated (7). Patients with non-terminal conditions can become terminal by choosing to forego life-extending treatments, such as dialysis. This has led to deaths in patients with non-terminal conditions; including anorexia, arthritis, and hernias (8). The wording of the proposed U.K. bill similarly allows for this broad interpretation, offering minimal protection to vulnerable patients (9).

Assessing capacity to make a life-ending decision is particularly fraught in patients with malnutrition or mental distress (10, 11) who may appear lucid and articulate, yet struggle to process information fully. Evidence suggests that clinicians’ judgments of capacity in these patients are often inconsistent (11). In Oregon, only three individuals who received lethal prescriptions (1%) were referred for psychiatric evaluation in 2023, down from 33% in previous years (12), raising concerns that evaluators have become less cautious about capacity and psychiatric comorbidities.

Moreover, evidence from jurisdictions where assisted dying is legal reveals weak oversight and opaque reporting mechanisms (13). For example, U.S. oversight agencies confirmed anorexia nervosa has been documented as a terminal illness in cases of assisted death; however, these cases are hidden in public reports under the broad category “Other Illnesses” (2). Officials declined to disclose the exact number of cases, and agencies have limited authority to investigate potential misapplications of the law.

In the UK, the Court of Protection has already allowed treatment withdrawal and palliative care for eating disorders deemed ‘untreatable’ (14). However, researchers have raised concerns that many patients are labeled 'untreatable' without having received adequate treatment (4). If the proposed bill passes, “palliative care for eating disorders” may expand to assisted dying, undermining protections for those with complex, often stigmatised mental health conditions.

Evidence from other jurisdictions should serve as a stark warning to UK policymakers. The question before Parliament is not only whether individuals have the right to die, but whether assisted dying can be safely implemented within the NHS. Evidence from other countries shows that safeguards intended to protect vulnerable patients from medically-assisted suicide have failed. We urge MPs to weigh these findings carefully and vote against the bill—it fails the public safety test.

Chelsea Roff
Executive Director, Eat Breathe Thrive

James Downs
Peer Researcher and Expert by Experience

Agnes Ayton
Consultant Psychiatrist in Eating Disorders
Oxford Health NHS Foundation Trust

Ashish Kumar
Chair, Faculty of Eating Disorders, RCPsych
Clinical Director at Mersey Care Foundation Trust

Angela Guarda
Professor of Psychiatry and Behavioral Sciences Director
Eating Disorders Program Johns Hopkins School of Medicine

Patricia Westmoreland
Medical Director, ACUTE Center for Eating Disorders & Severe Malnutrition Department of Psychiatry, University of Colorado

Philip Mehler
Founder, ACUTE Center for Eating Disorders & Severe Malnutrition
Professor of Medicine, University of Colorado

Mark S. Komrad
Faculty of Psychiatry
Johns Hopkins School of Medicine, Tulane, and University of Maryland

Paul Appelbaum
Dollard Professor of Psychiatry, Medicine & Law
Columbia University

Ronald W. Pies
Professor Emeritus of Psychiatry
SUNY Upstate Medical University

Annette Hanson
Assistant Professor
University of Maryland

Catherine Cook-Cotton
Licensed Psychologist, Professor and Researcher
University at Buffalo (SUNY)

Anita Federici
Clinical Psychologist
Center for Psychology and Emotion Regulation

Hope Virgo
Founder of #DumptheScales, Author,
Mental Health Campaigner

Ali Ibrahim
Consultant Psychiatrist, Eating Disorders

Suzanne Baker
Family & Carer Representative, FEAST UK

Marissa Adams
Peer Research & Expert by Experience

References
1. Looi, M. K. (2024). Assisted dying laws around the world. bmj, 387.
2. Roff, C., & Cook-Cottone, C. (2024). Assisted death in eating disorders: a systematic review of cases and clinical rationales. Frontiers in Psychiatry, 15, 1431771.
3. Gaudiani, J. L., Bogetz, A., & Yager, J. (2022). Terminal anorexia nervosa: three cases and proposed clinical characteristics. Journal of eating disorders, 10(1), 23.
4. Downs, J., Ayton, A., Collins, L., Baker, S., Missen, H., & Ibrahim, A. (2023). Untreatable or unable to treat? Creating more effective and accessible treatment for long-standing and severe eating disorders. The Lancet Psychiatry, 10(2), 146-154.
5. Robison M, Udupa NS, Abber SR, Duffy A, Riddle M, Manwaring J, Rienecke RD, Westmoreland P, Blalock DV, Le Grange D, Mehler PS, Joiner TE. "Terminal anorexia nervosa" may not be terminal: An empirical evaluation. J Psychopathol Clin Sci. 2024 Apr;133(3):285-296. doi: 10.1037/abn0000912. PMID: 38619462; PMCID: PMC11062513.
6. Westmoreland P, Krantz MJ, Mehler PS. Medical Complications of Anorexia Nervosa and Bulimia. Am J Med. 2016 Jan;129(1):30-7. doi: 10.1016/j.amjmed.2015.06.031. Epub 2015 Jul 10. PMID: 26169883.
7. Stahle F. Notarized Questions to Oregon Health Authority. January 2018. Available online: https://drive.google.com/file/d/1XopTDjBA2SAVBGBxpDazNN899eTHixSe/view
8. Oregon Health Authority. Oregon Death with Dignity Act: 2021 Data Summary (2022). Available online at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARC...
9. Leadbeater K. Terminally Ill Adults (End of Life) Bill. Nov 11, 2024. https://bills.parliament.uk/bills/3774 [Accessed 14th November 2024].
10. Van Elburg, A., Danner, U. N., Sternheim, L. C., Lammers, M., & Elzakkers, I. (2021). Mental capacity, decision-making and emotion dysregulation in severe enduring anorexia nervosa. Frontiers in Psychiatry, 12, 545317.
11. Elzakkers, I. F. F. M., Danner, U. N., Grisso, T., Hoek, H. W., & van Elburg, A. A. (2018). Assessment of mental capacity to consent to treatment in anorexia nervosa: A comparison of clinical judgment and MacCAT-T and consequences for clinical practice. International journal of law and psychiatry, 58, 27–35. https://doi.org/10.1016/j.ijlp.2018.02.001
12. Oregon Health Authority. Oregon Death with Dignity Act: 2023 Data Summary (2024). Available online at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARC...
13. Raikin, A. (2024). A pattern of non-compliance. The New Atlantis. 11 November 2024.
14. Cave, E., & Tan, J. (2017). Severe and enduring anorexia nervosa in the England and Wales Court of Protection. International Journal of Mental Health and Capacity Law, 23(17).

Netherlands woman (33) dies by euthanasia based on anorexia

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Esther Beukema with her mother.

Poppy Bilberbeck wrote an article that was published by Unilad.com on November 4 about the Netherlands euthanasia death of Esther Beukema (33) who died on December 10, 2021. Beukema was approved for euthanasia based on mental illness. Her condition was anorexia.

Bilberbeck's article describes Beukema's euthanasia death for anorexia in a positive manner. The article interviews the family and suggests that they were supportive of Esther's death and happy that she didn't die alone.

The article states that there was no other choice, when euthanasia is done for mental illness, and in this case for anorexia. Bilberbeck writes:

The Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act of 2002 states someone can be permitted euthanasia for psychiatric as well as physical illnesses if there is 'no reasonable alternative' and the patient's suffering is 'unbearable with no prospect of improvement'.

For people with anorexia there is always a reasonable alternative.

A landmark study by Chelsea Roff and Catherine Cook-Cottone titled: Assisted death in eating disorders: a systematic review of cases and clinical rationales, was published by Frontiers in Psychiatry on July 30, 2024.

The authors of the study responded by promoting a Joint Statement Against Assisted Suicide for Eating Disorders. The Joint Statement says:

Eating disorders are treatable conditions that require timely and comprehensive treatment. Yet many cannot access care due to cost, inadequate insurance coverage, extensive wait times, and a shortage of specialist services. The notion that they are incurable or terminal is scientifically unsupported and dangerously misleading. The term “terminal anorexia” is not recognized by any formal medical body, has been widely rejected by researchers and clinicians, and represents a profound misunderstanding of these conditions.

People with eating disorders need access to evidence-based and inclusive treatment, not lethal medications. Poor outcomes, including deaths, are nearly always preventable.We categorically reject the argument that assisted suicide is a form of compassionate care for individuals with eating disorders. Compassionate care involves consistent, effective treatment — not facilitating suicide. Together, we call on governments to act to ensure that every individual with an eating disorder receives the care, compassion, and treatment they need to recover.

The statement by the National Association of Anorexia Nervosa & Associated Disorders (ANAD) in June 2024 concerning euthanasia and anorexia stated:

We must not confuse ‘chronic’ with ‘terminal.’ Being labeled with a terminal illness has the potential to become a self-fulfilling prophecy.

I reject the concept that eating disorders are a terminal condition.

I am convinced that Esther Beukema was abandoned by the medical system. Her family would have wanted her to be happy, but in fact Esther was abandoned to death.

Assisted Suicide Laws Based On the Oregon Model Disproportionately impacts people with disabilities

This article was published by Not Dead Yet on August 23, 2024.

The Oregon model embodies the “better off dead than disabled” ethos in thin disguise.

Lisa Blumberg

By Lisa Blumberg, JD

In 2014, in connection with whether assisted suicide laws would ever be expanded to include people with cognitive decline, Barbara Coombs Lee, then director of Compassion & Choices, said, “It is an issue for another day but is no less compelling.” This was a momentary slip.

The political strategy of Compassion & Choices, the primary organizational proponent of legalized assisted suicide, has always been to sell the concept to state legislatures by asserting that it would only be an option for the dying. They advocate for the Oregon model where eligibility for a lethal prescription is limited to those who due to a terminal illness have less than six months to live. The argument goes that assisted suicide has nothing to do with disabled people except those who happen to be dying.

Scratch the surface and the picture is different. Legalized assisted suicide has a disproportionate impact on people with disabilities for several reasons.

First, virtually all people who are terminally ill have health related functional impairments. The leading reasons why individuals choose assisted suicide are disability related and psychosocial in nature such as perceptions of lessened autonomy. One study indicates that a fear of going into a nursing home – which is a quite reasonable fear for many people with disabilities – is much more likely to fuel a desire to hasten death than pain. In other words, people think about suicide not because death may be near but because they are unsure about how to deal with the practical problems and devaluation that come with needing help or accommodation in daily activities. As Vincenzo Piscopo, CEO of United Spinal Association has said, 

“inadequate resources to provide home care and fear of being a financial or care burden is the motivation for overwhelmed severely disabled people to kill themselves.”

Of the 884 people who died by ingesting lethal drugs obtained under California’s assisted suicide law in 2023, 45 people were reported to have ALS, 24 had Parkinson’s disease and 8 multiple sclerosis. The hallmark of these conditions, although they may have end stages, is physical disability.

The second reason is that for purposes of determining eligibility, doctors may take a very expansive view of what constitutes terminal illness. One example is anorexia. A Colorado doctor, who has provided lethal prescriptions to three young people with anorexia, has spearheaded an effort to recognize a new clinical disorder called “terminal anorexia”, which would apply to the small fraction of patients for whom “recovery remains elusive”. As recounted in the New York Times, the motivation for the label was that it would give people “a formal diagnostic acknowledgment that they were dying, making it easier for them to access hospice care — and even, should they want it, and should they live in a state where it is legal for terminally ill patients, and should their physicians be willing, a physician-assisted death.” This is circular reasoning. In my opinion, it is prognosis by semantics. Fortunately, there has been considerable pushback by both health professionals and advocates.

In Colorado in 2023 though, 9 people died by assisted suicide where the terminal condition was identified as “severe protein calorie malnutrition.” Before 2021, no such cases were reported. In California in 2023, 11 people reported to have endocrine, nutritional and metabolic disease died by assisted suicide. It is not known how many of these people in these states had eating disorders or restricted caloric intake for other reasons.

Third, the ethicist Thaddeus Pope promotes voluntarily stopping eating and drinking (VSED) as a “bridge” to assisted suicide under the Oregon model. He has described a case in Oregon where a woman with early dementia, who didn’t qualify for assisted suicide any other way, used VSED with the help and support of her medical team for four days whereupon she was diagnosed with the “terminal disease” of dehydration. She requested a lethal prescription and promptly received it, with the waiting period between the two requests being waived, because she now had a short life expectancy (without treatment). Pope is candid that she made herself terminally ill as determined by her doctors and is untroubled by it.

Every competent adult has the right to decide what to eat and drink and whether to eat or drink at all. The issue here is selectively promoting VSED as a back doorway to assisted suicide. This would mean that with a doctor’s cooperation, any significantly disabled person could meet eligibility criteria by manipulating circumstances to become terminally ill. Indeed, the idea of medical complicity in making someone eligible for assisted suicide is extremely chilling and has obvious implications for the whole disabled community.

The fourth reason is that in large part due to the health disparities we are subject to, people with disabilities face a greater incidence of physical and mental ailments, including obesity, diabetes, cardiovascular disease, addiction, and mental distress, as well as increased rates of morbidity and mortality. According to a piece in Stat, nearly half of people with disabilities say they are in bad health. Statistically, this means people with pre-existing disabilities become eligible for assisted suicide under the Oregon model before others do. Moreover, suicide prevention services are among the health care services that we struggle to access. It is a perfect storm.

None of this is surprising. The premise of assisted suicide laws is that a person’s health status may make it reasonable for them to kill themself. The Oregon model embodies the “better off dead than disabled” ethos in thin disguise.

Landmark study: Assisted death for eating disorders.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

A landmark study by Chelsea Roff and Catherine Cook-Cottone titled: Assisted death in eating disorders: a systematic review of cases and clinical rationales, was published by Frontiers in Psychiatry on July 30, 2024. Both authors are experts in the treatment of eating disorders (EDs).

Chelsea Roff recovered from
a serious eating disorder

The authors provided a systematic review of cases of euthanasia or assisted suicide for eating disorders by examining the assisted dying reports from jurisdictions that have legalized euthanasia and/or assisted suicide. The authors use the term assisted death because it encapsulates both euthanasia, the act of the physician or nurse, and assisted suicide, the prescribing of the lethal drugs whereby the person must self-administer.

The authors uncover at least 60 cases of assisted death based on eating disorders. There may be many more but countries, such as Canada, don't publish data that would enable them to uncover all of the assisted deaths for eating disorders.

Join the EPC webinar on August 9: Assisted Death for Eating Disorders with Chelsea Roff.

EPC is hosting a webinar: Assisted Death and Eating Disorders with Chelsea Roff on Friday August 9 at 11 am (ET).

Register for the Zoom webinar in advance. (Registration Link).

Chelsea Roff

After registering, you will receive a confirmation email containing information for joining the meeting.

Chelsea Roff is the co-author on a recent study on Assisted Death and Eating Disorders published by Frontiers in Psychiatry on July 30, 2024 which examined 60 known cases of euthanasia or assisted suicide for eating disorders.

During the webinar, Roff will discuss the cases that she researched for the study, she will discuss why eating disorders are not terminal, she will tell her own story, and she will explain how she helps people recover from eating disorders. We will leave time for questions.

Roff is the founder of Eat Breathe Thrive, which is an organization that helps people recovery from eating disorders. Roff herself recovered from anorexia.

Register for the Zoom event in advance. (Registration Link).

After registering, you will receive a confirmation email containing information for joining the meeting.

Further information on this topic:

• At least 60 people with eating disorders euthanized or assisted in suicide since 2012 (Link).
• ANAD clarifies that Anorexia Nervosa is not a terminal condition (Link)
• When I was Anorexic I would have chosen assisted suicide (Link).
• Psychiatrist: Anorexia does not justify Aid in Dying (Link).
• Anorexia is not a terminal condition (Link).

At Least 60 People with Eating Disorders Euthanized or Assisted in Suicide since 2012

This article was published by National Review online on August 1, 2024.

Register for the August 9 webinar: Assisted Death for Eating Disorders (Link).

By Wesley J Smith

“Strict guidelines protect against abuse” my left nostril.

Wesley Smith

A very disturbing — but, alas, unsurprising — report has been published from a review of medical studies that demonstrates that at least 60, but almost surely more, people with eating disorders (EDs) have been euthanized or assisted in suicide between 2012 and 2024. From the long, meticulously researched and thoroughly detailed study published by Frontiers in Psychiatry  (citations omitted):

We identified 10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024 (Table 4). Note that this figure does not represent the total number of patients with EDs who have undergone assisted dying in countries where it is legal. It represents only those which were identifiable via the limited data available in public reports.

This includes at least three patients from the U.S.:

One case study has been published in the United States (2), which described three patients, two of whom were prescribed MAiD. . . .

Of the 78 data reports reviewed from U.S. states where assisted dying is only legal for terminal conditions, which report on a total of 11,983 cases, none include reporting on psychiatric conditions. Only one report mentions an ED specifically. Oregon’s Death with Dignity Report noted that seven individuals were prescribed MAiD for Other Illnesses, of which anorexia was listed as an example condition in the footnote. It is unclear how many of those seven deaths were persons with anorexia.

All of the descriptive cases reported were of women:

Of the 60+ cases identified across all studies and reports, 19 included descriptive case summaries with information about the patients and the clinical rationales that were used to justify assisted death. All 19 patients were women. Specifically, 32% were under the age of 30 (N = 6), 37% were between the ages of 30 and 50 (N = 7), and 31% were over 50 years old (N = 6). 61% (N = 11) had been diagnosed with anorexia, one person was described as obese (but her ED was not specified), and 28% (N = 5) had EDs (but the specific diagnoses were not identified).

Most had other mental illnesses:

All but one person described in the case reports had multiple comorbid psychiatric diagnoses. Rates of comorbidity were high; 95% had more than one psychiatric disorder, 61% had more than three, and nearly a quarter had four or more comorbid conditions (Table 6). Specifically, obsessive compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) were common, occurring in 33% and 37% of cases respectively. One patient was described as having a mild intellectual disability, and 16% of patients (N = 3) had autism spectrum disorder. Nearly half of patients were diagnosed with at least one personality disorder.

Good grief. How might those mental disorders have affected these poor people’s ability to “choose” to be killed or kill themselves?

Also, the meaning of “terminal illness” was redefined to justify life terminations (my emphasis in bold):

In cases in the United States, where a terminal prognosis is a legal prerequisite for assisted death, authors asserted that ED patients prescribed MAiD had terminal conditions. . . .

Notably, this conception of terminality deviates from medical definitions of a terminal condition, by describing reversible cognitive behaviors (thoughts, thinking patterns, cognitive distortions) as indicators of a terminal illness (i.e., an understanding that treatment is futile, choosing to stop trying, and accepting death). Medical texts describe the terminal phase of an illness as a period of inexorable and irreversible decline leading to death, with no expectation of recovery and a survival prognosis of only months or less. Unlike cancer or Alzheimer’s disease, most medical complications associated with anorexia can be treated with adequate nutritional intake and weight restoration, even in severely emaciated patients. Furthermore, cognitive and emotional symptoms associated with anorexia, such as despair and cognitive distortions, also improve with effective treatment.

There is only one way to describe these cases: abandonment.

That’s certainly how 40 disability-rights, psychological, aging-advocacy, and anti-assisted-suicide organizations see it. From their Joint Statement against Assisted Suicide for Eating Disorders:

Eating disorders are treatable conditions that require timely and comprehensive treatment. Yet many cannot access care due to cost, inadequate insurance coverage, extensive wait times, and a shortage of specialist services. The notion that they are incurable or terminal is scientifically unsupported and dangerously misleading. The term “terminal anorexia” is not recognized by any formal medical body, has been widely rejected by researchers and clinicians, and represents a profound misunderstanding of these conditions.

Moreover:

People with eating disorders need access to evidence-based and inclusive treatment, not lethal medications. Poor outcomes, including deaths, are nearly always preventable.

Indeed.

Please stop buying the demonstrable nonsense that the legalization of assisted suicide would be a minor change in ethics. Once the legalization train leaves the station, it is no longer containable or controllable. Or, to put it another way, once a society decides that killing is an acceptable answer to human suffering, the category of “killables” never stops expanding.

Joint Statement Against Assisted Suicide for Eating Disorders

Register for the August 9 webinar: Assisted Death for Eating Disorders (Link).

The Euthanasia Prevention Coalition signed the Joint Statement Against Assisted Suicide for Eating Disorders 

(Link to the Eat Breathe Thrive Joint Statement)

We, the below signatories, urge governments everywhere to take immediate action to address the unethical practice of assisted suicide for individuals with eating disorders. This practice undermines decades of research on effective treatments and endangers the lives of vulnerable individuals.

A recent study revealing at least sixty published cases of assisted suicide and euthanasia among patients with eating disorders in Belgium, the Netherlands, and the United States, raises significant public safety concerns. A third of the cases involved young people in their teens and twenties, some of whom had never received comprehensive treatment before they were assisted in suicide. This highlights a tragic failure of healthcare systems, legal safeguards, and a grave violation of physicians’ ethical duty to do no harm.

Eating disorders are treatable conditions that require timely and comprehensive treatment. Yet many cannot access care due to cost, inadequate insurance coverage, extensive wait times, and a shortage of specialist services. The notion that they are incurable or terminal is scientifically unsupported and dangerously misleading. The term “terminal anorexia” is not recognized by any formal medical body, has been widely rejected by researchers and clinicians, and represents a profound misunderstanding of these conditions.

People with eating disorders need access to evidence-based and inclusive treatment, not lethal medications. Poor outcomes, including deaths, are nearly always preventable.

We categorically reject the argument that assisted suicide is a form of compassionate care for individuals with eating disorders. Compassionate care involves consistent, effective treatment — not facilitating suicide. Together, we call on governments to act to ensure that every individual with an eating disorder receives the care, compassion, and treatment they need to recover. We urge policymakers, healthcare providers, and the broader community to take immediate action by doing the following:

1. Prevent Assisted Suicide for Eating Disorders: Legally prevent eating disorders from being considered qualifying conditions for assisted suicide.
2. Strengthen Oversight and Reporting: Ensure reporting on assisted death includes psychiatric conditions. Establish review boards and create clear pathways for members of the public, officials, and healthcare professionals to investigate and report violations.
3. Amend Existing Safeguards: Review the existing safeguards on assisted suicide to ensure that eligibility terms like ‘terminal condition,’ ‘mental capacity,’ and ‘irremediable condition’ are clearly and operationally defined by law.
4. Increase Access to Eating Disorder Treatment: Invest in improving access to high-quality, timely treatment for eating disorders, focusing on long-term recovery and support.
5. Increase Research Funding: Invest in research to develop more effective treatments for eating disorders, particularly for individuals with severe and chronic conditions.

Link to become a signatory (Link).

Further information on this topic:

• ANAD clarifies that Anorexia Nervosa is not a terminal condition (Link)
• When I was Anorexic I would have chosen assisted suicide (Link).
• Psychiatrist: Anorexia does not justify Aid in Dying (Link).
• Anorexia is not a terminal condition (Link).

Anorexia is not a terminal condition.

The following letter was sent to EPC from a woman in Honduras who was responding to a previous article concerning people with Anorexia dying by assisted suicide based on Anorexia being falsely defined as a terminal illness.

I couldn't sleep. I was really skinny in 2004.

I was daddy's little girl whom I lived with when he was diagnosed with stomach cancer. I suffered anorexia since 2004 without knowing that when dad was diagnosed with stomach cancer, I almost died. I couldn't work. I didn't eat. I tried and tried, but mom and I were focused on my father's illness.

My dad passed away on September 3rd, 2007, and I was really skinny, I didn't want to eat not exactly (that I didn't want to eat, I wasn't able to eat and got seriously depressed).

Fortunately, a Medical Doctor, an Internist of Tegucigalpa capital city of my hometown, Honduras Central America where I live, learned of my problem of Anorexia. What would I do without him and the Psychiatric treatment from another doctor, again and again what would I do without him?

Both helped me out when I suffered Anorexia and I can't thank them enough for the way they treated me with ethics and humanity. I will always be grateful for them. 

Now I work with elderly people and feel really happy with my job position and I am totally recovered of Anorexia. Thanks be to God and the physicians mentioned above!

Sincerely,

Eunice Lozano Oqueli from my hometown, Honduras Central America.

More information on this topic:

• ANAD clarifies that Anorexia Nervosa is not a terminal condition (Link)
• When I was Anorexic I would have chosen assisted suicide (Link).
• Psychiatrist: Anorexia does not justify Aid in Dying (Link).