Assisted suicide lobby launches court case to force Colorado to permit suicide tourism.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

On May 22, the assisted suicide lobby filed a federal lawsuit on behalf of Jeff McComas and two Colorado physicians challenging the state assisted suicide law residency requirement. 

The complaint argued that the Colorado assisted suicide law residency requirement violates the U.S. Constitution’s Privileges and Immunities Clause which “prohibits State officials from restricting non-resident visitors’ access to medical care within its borders absent a substantial State interest and restrictions narrowly tailored to those interests.”

The assisted suicide lobby made the same arguments in Oregon, Vermont and New Jersey. Oregon and Vermont subsequently removed their state assisted suicide law residency requirement whereas New Jersey has successfully defended their state assisted suicide law residency requirement in the court.

Jeff McComas's rights are not being infringed by Colorado's assisted suicide law that limits lethal poison prescriptions to state residents.

First: Oregon and Vermont will assist the suicide of out-of-state residents. McComas has access to assisted suicide in Oregon and Vermont, therefore his constitutional rights are not being violated.

Second: Assisted suicide is not a form of medical treatment or care therefore the Privileges and Immunities Clause does not apply to assisted suicide.

Colorado legalized assisted suicide by passing Proposition 106 during the November 2016 election. In 2024, Colorado passed Senate Bill 24-068 expanding their assisted suicide law by: 

• allowing advanced practice registered nurses to approve and prescribe lethal poison, 
• reducing the waiting period from 15 days to 7 days, and
• allowing doctors or advanced practise registered nurse to waive the waiting period if the person is near to death.

The original version of SB 24-068 allowed non-residents to die by assisted suicide in Colorado but this amendment was rejected by legislators.

The 2024 Colorado assisted suicide report indicated that there were 510 lethal poison prescriptions written in 2024 up by 28% from 398 in 2023. 18 of the lethal poison prescriptions were based on the person having an eating disorder.

Colorado assisted suicide deaths increase in 2023.

Alex Schadenberg
Executive Director,
Euthanasia Prevention Coalition

The 2023 Colorado assisted suicide report indicates that assisted suicide poison prescriptions and deaths have continued to rise every year since legalization.

Even though the number of assisted suicide deaths is continually increasing Colorado Governor Gary Polis signed Senate Bill 24-068 on June 5 to expand their State assisted suicide law. Nearly every state that has legalized assisted suicide has expanded their law.

The Colorado assisted suicide report indicated that in 2023 there were 389 lethal poison prescriptions written, which was up by more than 22% from 318 in 2022, 218 in 2021 and 185 in 2020.

The Colorado report indicated that in 2023, 294 of the lethal poison prescriptions were dispensed which was up by more than 18% from 249 in 2022, 164 in 2021 and 149 in 2020.

The data seems confusing since Colorado collects information on the number of lethal poison prescriptions that are written and it collects information on the number of lethal poison prescriptions dispensed but it doesn't collect information on how many people actually died by assisted suicide.

We expect that the 2024 Colorado assisted suicide report will show more increases in deaths now that Colorado expanded their assisted suicide law in 2024.

The assisted suicide lobby knows that it is harder to legalize assisted suicide than to expand the law once it is legal. Nearly every state that has legalized assisted suicide has later expanded their law.

Jacqueline Abernathy opposing Colorado assisted suicide expansion Bill SB 068

Dear Honorable Members of the Colorado State Assembly Senate Health & Human Services Committee,

Jacqueline Abernathy

I write today to urge you to oppose SB 068 and its blatant attempt to welcome suicide tourism in Colorado and put Coloradans at risk by expanding assisted suicide access to non-residents. I implore you as a public policy scholar fearful of how Colorado could betray the safety of its own most vulnerable citizens simply to put other citizens at risk as well. Your bill is a gross overstep to endanger citizens in other states while increasing the threat to your own constituents. 

I speak as an expert on this very topic, a bioethicist with a Ph.D. in Public Administration and Policy and a bibliography of scholarly peer-reviewed publications on assisted suicide and end-of-life medical decision-making. Where your duty is to the people of Colorado, entertaining the overreach inherent to SB 068 betrays the health and safety of those you are called to protect. This is why all eyes are upon you and non-residents like myself, who have an equal entitlement to weigh in on your decision in Colorado.

Regardless of what instigates it, suicide is generally an impulsive act of desperation, most often borne of fear. Enabling hasty irreversible decisions to self-destruct is not meant to limit any negative outcomes to the patient through delays. This bill will simply accommodate non-residents who travel to Colorado to obtain a deadly prescription from a total stranger who will only have them as a patient as long as it takes to dispense the lethal dose. SB 068 would create a market for these niche practices that do nothing but dispense deadly suicide drugs. The provisions negated in SB 068 include competent physician requirements, reflection and review periods, second opinions about prognoses and mental capacity, and the independence of physician assessments of each patient’s case. This bill eschews any semblance of an existing doctor-patient relationship by a physician well acquainted with the patient and their particular set of circumstances. SB 068 does not feign to value doctor opinions at all, striking every use of the word “physician” in favor of provider in order to allow lesser-qualified non-physicians to dispense the deadly poisons in a fraction of the time. This appears to accommodate specialty death clinics of ideologically pro-euthanasia on-demand doctors and nurses who can blindly validate each other’s conclusions out of their position that death on demand is a personal right for those who meet any legal or ethical criteria. This directly affronts the reason for the Colorado law to require a consultative review: as a safeguard to independently assess and concur with the attending physician’s conclusion that a patient is indeed terminally ill and mentally competent without signs of coercion or duress.

SB 068’s embrace of logistics to enable vendor suicide businesses negates any remaining provisions meant to protect Colorado citizens as total smokescreen. Whereas 14 days was the length of time for a resident advised by their existing doctor, surrounded by their family, greater community, extended support network and familiar resources, now anyone can visit a clinic for a rubber-stamped approval to kill themselves within two days. It strikes time for an adequate review of each patient’s case, limiting opportunity for further reflection by patients. There is no time for scrutiny or basic due diligence regarding someone’s alleged terminal prognosis and increases the likelihood of patient misdiagnosis and the possibility of treatable depression. A review of studies also determined that physicians’ medical diagnoses were often incorrect, both in declaring a patient to have a terminal condition and estimating their life expectancy at six months or fewer. Another study of physicians who were willing to prescribe the lethal dose found that 27 percent were not confident that they could determine if a patient only had six months or fewer to live. There is also substantial evidence that many patients opting to end their lives suffer from treatable depression and physicians report that patients for whom interventions were made (like treating depression) were more likely to change their minds about wanting to end their lives.

Whereas tax exportation to increase state budgets by encouraging tourism is within your scope as lawmakers, this would only increase revenue at the invaluable health and safety expense of those citizens who no longer have any safeguards thanks to enabling non-residents, but furthermore, this does not factor in the actual monetary and human costs of cleaning up after the deceased. 

The bill assumes that non-residents would just be trying to subvert their own state laws against assisted suicide but how many might be trying to subvert loved ones back home as well or have no one to return to anyway? While it is true that most suicides (77%) occur at home, those who travel here from their homes out-of-state just to obtain deadly drugs because SB 068 designed this option for that express purpose that they will not leave alive. Where do suicidal people who don’t have as ready access to their home as a place to end their lives? National parks are prime suicide destinations as is, particularly in the west where suicide the second leading cause of death, costs over a quarter-million dollars in recovery and identification efforts per victim. The Colorado National Monument attracts dozens of despondent people who self-destruct each year, but with the means to death in their pocket, any public place can become the spot someone chooses to die if they are inclined. There can only be added costs and psychological trauma to the Colorado residents who will face the aftermath of inviting this added violence. Mere exposure to suicide often leads to suicide among the responders and survivors, and this is true of those who discover a deceased loved one at home. For every quick, exported suicide that was started in Colorado but completed in a neighboring state for those residents to deal with the unpleasant consequences, there are sure to be secret, expedited death plans of residents enabled by SB 068. Making suicide so quick and easy can only mean more shocked survivors of hasty death plans by Coloradans hiding their intentions, leaving notes for their children or spouses explaining that they sought a hasty overdose from a nurse in Denver just days after learning their diagnosis because they “didn’t want to be a burden,” never knowing that their grieving survivors would give anything to have had a chance to tell them how desperately their family wanted to care for them for what precious time they had left.

In a state that ranks among the highest for per capita suicides (46 out of 50), so this would merely add a so-called legitimate form of self-violence to what your state calls a “public health crisis” and cost enormous sums of tax dollars to prevent. SB 068 only serves to usher in more death and destruction of Colorado residents by inviting the death and destruction of non-residents. Attempting to usurp the laws of other state legislatures to impose your will can only be done by endangering and burdening the citizens you are called to protect. 

Do your duty. Vote NO on SB 068.

Sincerely,

Jacqueline Harvey Abernathy, Ph.D., M.S.S.W.
Dallas, Texas

Lethal assisted suicide drugs were accidentally ingested in Colorado.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

I was cleaning up my emails and found a report that was published in the Journal of Emergency Medical Services on November 29, 2022 titled: Death with Dignty: When the Medical Aid in Dying cocktail gets into the Wrong Hands. 

The report concerns an emergency whereby a 35-year-old man in Colorado self-administered part of a lethal cocktail of assisted suicide drugs. The report states:

Ambulance 64 is dispatched to a 35-year-old male with possible alcohol overdose. Upon arrival, the crew is directed to a back bedroom where they find two fully clothed males with their legs hanging off a bed. One is elderly, the other is middle aged. Both are unconscious and unresponsive with shallow respirations. A bystander hands a medicine bottle to the attending paramedic frantically saying, “They drank this! They drank this!” The bottle contains digoxin 100 mg, diazepam 1,000 mg, morphine 15,000 mg, amitriptyline 8,000 mg and phenobarbital 5,000 mg. She remarks that the older man “should be dead” and the younger one “should be alive.”

The bystander states that the older man is a “death with dignity” patient who invited loved ones to be present while he consumed the MAID medication. After his first swallow, he remarked, “Man that burns!” The younger man said, “Let me see,” and then also took a swallow. The attending paramedic directs rescuers to begin ventilating the younger man while requesting evidence of advance directives for the older man. Care was not rendered to the death with dignity patient because he had a valid Medical Orders for Scope of Treatment (MOST) form stating he wanted no lifesaving measures performed on him. The medication bottle was prescribed to the patient. Hospice was contacted to verify he was a terminally ill patient of theirs. Medical control was also contacted for a consult because this was not a typical call.

The younger male patient is found to be atraumatic. His skin signs were significant for cyanosis but otherwise warm and dry. Pupils were constricted, equal and reactive. Without ventilations, his respiratory effort is 6; Sp02 was 72%. The patient is placed on a cardiac monitor and the heart rate is recorded at 144 bpm, blood pressure is auscultated and found to be 134/96 mmHg. Blood glucose is 172 mg/dl. Intravenous access is achieved with a 16-gauge catheter placed in his right external jugular vein. After there is no change in the patient’s presentation following Narcan 2 mg via IV, he is endotracheal intubated. End tidal carbon dioxide is then measured at 56 mmHg. The receiving facility is notified that a patient with a massive polypharmacy ingestion is en route.

...This challenging case is an excellent illustration of the importance of prehospital providers to have an understanding of end-of-life-care as it pertains to advanced directives and to be aware they may practice in an area where they encounter patients who may be in a MAID program. In this case, the paramedic had to juggle a complicated scene with two potential patients who both were near death. Education regarding such programs should be a priority to EMS agencies, as is how to handle instances where family members are requesting that no resuscitation be attempted and either advance directives are not in place, or copies of them cannot be located.

The report continues with information about the recovery of the man who self-administered the lethal cocktail without legal permission and it then concludes:

Should accidental ingestion occur, care is mainly supportive. The patient should be placed on a cardiac monitor and have a 12-lead rhythm strip to evaluate for QRS prolongation and consideration of sodium bicarbonate administration. Continuous pulse oximetry monitoring and assisting ventilation as necessary is indicated. If necessary, placement of advanced airway with assisted ventilations with BVM and confirmation by end-tidal CO2 is appropriate. Intravenous or intraosseous access should be obtained and intravenous fluids can be administered if the patient is hypotensive. Naloxone can be trialed, although may not have much effect given the high dose of opiates in the compound. Consideration may be made for transport to an ECMO capable facility.

The US states that have legalized assisted suicide have done so in a completely irresponsible manner. Prescribing a lethal cocktail of drugs for suicide is always ethically wrong, but to do so without monitoring is irresponsible.

Is it possible that a grand child could find the lethal assisted suicide cocktail by the bed side or in the medicine cabinet? What happens to the lethal drugs that are not consumed?

The concept of freedom to choose to die is a lie. People don't ask for a lethal drug cocktail to express their freedom but rather it is a reaction to a social abandonment that has left them feeling that there is no hope, purpose or value to continuing life.

Colorado court: Defense of consent does not apply to man who killed his terminally ill wife.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Bruce Bagwell was convicted of first-degree murder for killing his terminally ill wife on February 6, 2019 in Colorado. Bagwell appealed his conviction by claiming a "defense of consent." 

Last week, a three judge court of appeal panel decided that a "defense of consent" was not available to him because his act caused a serious injury (death) and his act was intentional. This is an interesting decision based on the fact that Colorado legalized assisted suicide in 2016.

According to the court decision:

In the hour after the shooting, Bagwell admitted to his wife’s father, his wife’s sister, and the arresting officers that he shot his wife because she asked him to do so to end her suffering. He told law enforcement that his wife had begged him to shoot her each of the preceding five days, and he explained that it was a “mercy killing.” In a videotaped interrogation, Bagwell again admitted to two detectives that he had killed his wife.

Bagwell was tried and convicted of first degree murder in October 2019 and appealed the decision by contending the trial court erred by denying him a defense of consent.

The court of appeal found that Bagwell cannot claim a defense of consent the injury was serious (caused death) and Bagwell clearly intended to cause death. 

An article by Michael Karlik published in The Gazette stated:

"An injury that causes a victim’s death is necessarily 'serious,'" wrote Judge W. Eric Kuhn in the panel's April 21 opinion, "because it involves a permanent and dangerous impairment of the victim’s physical condition. The consent defense is not available, then, when a defendant intentionally kills a victim who consents to her own death."

When reading the court decision, the court of appeal did not find signs of pressure from the police, Bagwell freely confessed to the crime.

Considering the nature of the act, the use of the defense of consent should also apply to euthanasia and assisted suicide. 

The euthanasia lobby argues that they are carrying out the wishes of a person who has asked to die. The act of euthanasia, which is usually done by lethal injection, intentionally causes the death of the person. Whether a person has requested it or not, precedent should apply to the act, that being, there is no defense to consent when intentionally killing another person.

Significant non-compliance with Colorado assisted suicide law.

This article was published by the Australian Care Alliance.

Colorado’s experiment in providing a safe regime for assisted suicide is a failure because it lacks any possibility of identifying problems and, five years in, authorities remain lackadaisical about significant non-compliance even with the minimal reporting requirements.

In more than one in five cases the physician failed to lodge a copy – as required by law - of the person’s written request. In more than one in four cases the physician failed to lodge the mandatory written report from the consulting physician. 

In 2021 nearly one in seven cases even the basic form from the attending/prescribing physician has not been lodged and for which even the supposed assurance given by all the boxes being ticked is not provided.

Assisted suicide has been legal in Colorado since 16 December 2016 following the passing of a ballot initiative.

Minimal  data

Five annual reports have been published with the latest covering 2021.

Even compared to the limited data reported annually in Oregon and Washington the annual reports are sparse and uninformative.

In 2021 prescriptions for a lethal substance were written for 222 people – an 18% increase from 2021 and more than three times (308%) the number of prescriptions written in 2017.

For 2021 records of the lethal substance actually being dispensed were lodged for 156 (70.3%) of these cases.

A range of experimental lethal cocktails were dispensed, including combinations of diazepam, digoxin, morphine sulfate, and propranolol (DDMP or DDMP2 – 32 cases, 20.5%), with amitriptyline instead of propranolol (DDMA – 67 cases, 42.9%), and DDMA with the addition of phenobarbital (DDMAPh – 57 cases, 36.5%).

It is not known whether the prescription was not dispensed in the other 66 cases or if the mandatory paperwork was simply not lodged. 

Death certificates for 189 people for whom a lethal prescription had been written were received. However, as the death certificates, by law, only record the underlying illness and make no mention of whether death was caused by ingesting a lethal substance, it remains unknown how many of these 189 people actually died from the lethal substance or even collected it.

The youngest person who has been prescribed a lethal substance was reported as aged in the “upper 20s”.

There is no requirement (or even any process) for reporting complications for people from taking the lethal substance despite the mandated written declaration under the law requiring a person to acknowledge “although most deaths occur within three hours, my death may take longer”. The record length of time from ingestion to death reported from Oregon is 104 hours (4 days 8 hours).[3]

Although the law requires a referral to a psychiatrist or psychologist “if the attending physician believes that the individual may not be mentally capable of making an informed decision” only 5 out of 777 (0.64%) of those people for whom a lethal prescription was written (2017-2021) were first referred for an assessment., with no referrals reported for 2021.

Although eligibility is supposedly limited to a “terminally-ill individual with a prognosis of six months or less to live” the maximum duration of time between the date of prescription and date of death was “approximately 11 months”, with once case of “approximately eight months” in 2021.

“Other”, unspecified conditions

The 2021 report includes 8 cases of a lethal prescription written for “other illnesses/conditions” with no indication of what these were. This is double the 4 reported each year in 2019 and 2020.

A Colorado medical practitioner, Dr Jennifer Gaudiani, has reported acting as a consultant in two out-of-state cases of the prescription of a lethal substance for two 36 year old women with anorexia.[4]

With no details given in the Colorado reports on “other illnesses/conditions” we may never know when cases of a prescribing a lethal substance for anorexia or other non-terminal illnesses, including mental illnesses, occurs.

Significant non-compliance by physicians

What is most concerning is the level of non-compliance by physicians who prescribe lethal substances with even the very minimal reporting requirements.

In more than one in five cases (22.4%) from 2017-2021 the physician failed to lodge a copy – as required by law - of the person’s written request.

In more than one in four cases (25.5%) the physician failed to lodge the mandatory written report from the consulting physician. 

But the Colorado Board of Health is relaxed about this massive rate of non-compliance:

While reporting of the required documentation (including prescribing forms, patients’ written requests, consulting physicians’ written confirmations, and mental health provider confirmation) may be incomplete, all attending/prescribing forms received contained physicians’ signed attestations that all requirements of the Colorado End-of-Life Options Act have been met, and that required documentation is complete and contained in patients’ records. Efforts continue to educate physicians and other health care providers about reporting requirements.

This lay back approach glosses over the  13-15% of cases in each year from 2017 to 2021 where even the basic form from the attending/prescribing physician has not been lodged and for which even the supposed assurance given by all the boxes being ticked is not provided. There was 14.9% non-compliance with this legal requirement in 2021 – up from the lowest level of non-compliance of 12.9% in 2018.

Conclusion

Colorado’s experiment in providing a safe regime for assisted suicide is a failure because it lacks any possibility of identifying problems and five years in authorities remain lackadaisical about significant non-compliance even with the minimal reporting requirements.

Download a fact sheet on Colorado (PDF Link).

Assisted suicide for anorexia nervosa expands assisted suicide from terminal to chronic conditions.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In January I wrote an article about assisted suicide for anorexia nervosa. In the article I quoted from a case report published by the ACAMAID, an organization of assisted suicide practitioners who approved assisted suicide for anorexia nervosa by defining the condition as being "terminal." 

An article by Jennifer Brown that was published in the Colorado Sun on March 14 reports on Dr. Jennifer Gaudiani, an internal medicine doctor who specializes in eating disorders and who published a paper on her experience with prescribing assisted suicide for three people with anorexia nervosa.

Gaudiani defines anorexia as a terminally illness. Colorado's assisted suicide law does not permit assisted suicide for chronic or mental illnesses. Gaudiani considers anorexia to be a terminal condition because of the high rate of death among those who struggle with the condition. Brown writes:

In the paper, published in February in the Journal of Eating Disorders, Gaudiani ... writes that, although anorexia doesn’t have delineated levels of severity like cancer, which has stages of progression and a terminal phase, it can be brutally lethal. It is widely believed to have the second-highest mortality rate of all mental illnesses, behind only substance use disorders.

Based on the fact that anorexia has the second-highest mortality rate of all mental illnesses, second to substance use disorder, does that mean that people with substance use disorder also qualify for assisted suicide?

Is anorexia nervosa a terminal or a chronic condition?

A study by Kamryn Eddy et al., published in the Journal of Clinical Psychiatry in February 2017 titled: Recovery from Anorexia Nervosa and Bulimia Nervosa at 22 year Follow-Up recognizes that some people with Anorexia Nervosa die from the condition, but the study considers anorexia nervosa to be a chronic condition, not a terminal condition. The study is based on a 22 year follow-up and it concludes that for many people recovery is slow but nearly two-thirds of the participants fully recovered by year 22.

The study by Eddy is significant as it began in 1987 and followed up the participants at regular intervals including the 9 year interval and the 22 year interval. The study found:

Results:
At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa but not in bulimia nervosa.

Conclusion:
At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.

There are several significant findings in this study:

1. Recovery from anorexia nervosa was slower than bulimia nervosa. Whereas 31.4% of the participants with anorexia nervosa were fully recovered by year 9 and 62.8% were fully recovered by year 22, with bulimia nervosa 68.2% were fully recovered by year 9 and 68.2% were fully recovered by year 22.

In both anorexia nervosa and bulimia nervosa, some of the participants who had fully recovered by year 9 were no longer fully recovered by year 22, but that also suggests that these are chronic conditions. Anorexia nervosa often requires a longer term treatment commitment to achieve full recovery which also indicates that anorexia nervosa is a chronic condition andnot a terminal condition.

2. The data in the study indicates that of the 246 study participants 18 people were known to have died by the 20 - 25 year interval. There is some missing data since researchers lost contact with 15 of the participants, and 37 participants decided not to continue participating in the study, nonetheless, if anorexia nervosa were a terminal condition the death rate by the 20 - 25 year interval would be much higher. The study does not indicate if all of the 18 participants who were known ot have died, died from the chronic condition or if some died from another cause.

Eddy refers to a study by Hay and colleages who suggested that:

“both the clinician and [chronically ill] patient often share the experience of hopelessness and despair about the likelihood of meaningful change.”

I suggest that feelings of hopelessness and despair are leading assisted suicide clinicians to redefine anorexia nervosa as a terminal illness and thus prescribe death as a treatment.

The recent Oregon 2021 assisted suicide report also listed anorexia as a reason for assisted suicide.

 My earlier comments that assisted suicide for anorexia nervosa is abandonment is supported by the conclusion of the study which states:

Our data indicate that the majority will recover from anorexia nervosa and bulimia nervosa over time. Yet 2 decades of illness represents considerably meaningful life lost, and our findings emphasize the importance of developing interventions to reduce the duration of illness. Our findings that recovery remains possible even after long-term illness argue for active treatment rather than palliative care for most patients. Increased research attention to identifying early predictors, mediators, and moderators of recovery in naturalistic and controlled treatment trials is needed to guide treatment disposition recommendations.

By prescribing lethal drugs for assisted suicide or lethally injecting a person (euthanasia) the clinician is abandoning the patient rather than helping the patient find hope with the potential of long-term recovery.

Assisted suicide for anorexia is abandonment

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In January I wrote an article about assisted suicide for anorexia. In the article I quoted from a case report published by the ACAMAID, an organization of assisted suicide practitioners who approved assisted suicide for anorexia and stated:

If the patient’s eating disorder treating physician and evaluating psychiatrist agreed that she had a “terminal disease” and retained decision-making capacity, she would meet those requirements of the aid in dying statute in her jurisdiction.

An article by Jennifer Brown that was published in the Colorado Sun on March 14 reports on Dr. Jennifer Gaudiani, an internal medicine doctor who specializes in eating disorders, who has published a paper on her experience with approving assisted suicide for three people with anorexia.

Colorado's assisted suicide law does not permit assisted suicide for mental illness therefore Gaudiani has defined anorexia as a  terminally ill. Gaudiani considers anorexia to be a terminal condition because of the high rate of death among those who struggle with the condition. Brown writes:

In the paper, published in February in the Journal of Eating Disorders, Gaudiani advocates for allowing patients who are dying from anorexia to end their lives on their own terms. She writes that, although anorexia doesn’t have delineated levels of severity like cancer, which has stages of progression and a terminal phase, it can be brutally lethal. It is widely believed to have the second-highest mortality rate of all mental illnesses, behind only substance use disorders.

Based on the fact that anorexia has the second-highest mortality rate of all mental illnesses, second to substance use disorder, does that mean that people with substance use disorder also qualify for assisted suicide?

This is abandonment. Even the ACAMAID consultation service acknowledged that:

There is no consensus in the eating disorder literature regarding whether a patient who has severe enduring anorexia nervosa is “terminally” and “irreversibly” ill according to the definition in the State statute.

The recent Oregon 2021 assisted suicide report also listed anorexia as a reason for assisted suicide.

People with anorexia have a high mortality rate and many people live with anorexia for many years, nonetheless, the Beat Eating Disorders website contains multiple stories of people who were treated and successfully recovered.

I am not suggesting that everyone recovers from an eating disorder. I am saying that assisted suicide for anorexia is abandonment. Death by assisted suicide denies the opportunity to recover. 

My experience with assisted death is that once someone is convinced that death is their only option, treatment becomes more difficult since thd person is focused on death and not recovery. Assisted suicide is not about the "freedom" to die, but rather it is about medical abandonment.

Assisted suicide deaths are not what you think they are.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

David Rose, writing for the Daily Mail UK published an article on October 21 titled: Why an 'assisted death is almost certainly not what you think it is. Stories about how assisted suicide deaths actually occur are rarely published. Recently researcher Dr Joel Zivot has challenged how deaths by assisted suicide actually occur in his article - Assisted Suicide is neither painless nor dignified.

Rose states that assisted suicide deaths will often take many hours. Rose writes about the death of Colorado resident Kurt Huschle who died by assisted suicide in July 2017. Rose writes:

On the morning of July 16, a nurse arrived at their home and checked that Kurt stood by his decision. By noon, he was ready to go. Following the directions given, Susan mixed the contents of two small bottles into a bigger one and gave it to Kurt.

She had expected him to drink the drug cocktail, share a last hug, then pass away peacefully.

Instead, as Susan later told the Denver Post newspaper: ‘With every sip he’s choking and coughing, choking and coughing.’

After 20 minutes, she said, he began to gasp unevenly. He seemed to have lost consciousness. But more than four hours after he took the drugs, he was still alive.

Scared and upset, Susan called a doctor and asked for help. It was then the thought struck her that, like many dying patients, Kurt might still be partly conscious and able to hear her.

At 8.15pm, more than eight hours after Kurt took the drugs, he sat up in bed, retched and finally stopped breathing.

Susan said she still believed it was right to help him die. But it had not been a peaceful farewell and they had not been able to say goodbye as she had wanted.

The Oregon 2019 assisted suicide report states that the time of death ranged from 1 minute to 47 hours but the report didn't indicate how many people died more than 90 minutes after taking the lethal drugs.

Assisted suicide drug experimentation.

Assisted suicide activists have been experimenting for several years with lethal assisted suicide drug cocktail experiments to find a cheaper way to cause death. 

An article by Lisa Krieger published by the Medical Xpress on September 8, 2020 uncovers information about the lethal drug experiments:

A little-known secret, not publicized by advocates of aid-in-dying, was that while most deaths were speedy, others were very slow. Some patients lingered for six or nine hours; a few, more than three days. No one knew why, or what needed to change.

"The public thinks that you take a pill and you're done," said Dr. Gary Pasternak, chief medical officer of Mission Hospice in San Mateo. "But it's more complicated than that."

An article published in USA Today in February 2017 examined the experiments  being done on people to find a cheaper lethal drug cocktail for assisted suicide. The article states that assisted suicide researchers are promoting new generations of lethal drug cocktails. The results of the first two lethal drug cocktails were:

The (first) turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain. The second drug mix, used 67 times, has led to deaths that stretched out hours in some patients — and up to 31 hours in one case.

The 2020 Oregon report emphasizes the use of the fourth generation of lethal drug cocktails show that the length of time to die has reduced but the problems with the use of these lethal drug cocktails continue.

 

Link to video by Dr William Toffler of Oregon on this topic (Link).

Dr. Anne Hanson's Testimony Opposing Assisted Suicide

Suicide Contagion; Safeguard Failures; and Implications for the Practice of Psychiatry 

This article was published by Choice is an Illusion.

Anne Hanson MD

The Maryland Psychiatric Society opposes HB 643, the End-of-Life Option Act. Since this bill was first introduced in 2015, the Maryland Psychiatric Society has extensively deliberated the legislation within the organization through several listserv discussions, a member survey, and a four hour pro-con debate sponsored jointly with the Maryland somatic physician's organization, Med Chi. In addition to reviewing the legislation each year, we considered information contained in the American Psychiatric Association's resource document on assisted suicide (APA 2017) and other literature as cited in the references below.

The Maryland Psychiatric Society recognizes that this is a divisive issue and that some of our members disagree with the organization's position. Those members have been encouraged to contact their elected officials to contribute their thoughts and we welcome consideration of both sides of this serious policy.

The Maryland Psychiatric Society maintains its opposition to HB 643. There are three general areas of concern.

1. Suicide Contagion

Promotion of this bill, and assisted suicide laws generally, transmit a dangerous message to vulnerable Maryland citizens. According to the Centers for Disease Control,  at any given point in time 4% of people are experiencing suicidal thoughts. One-sixth of those individuals will attempt suicide (1.4 million Americans), and 3% will die (Shreiber and Culpepper 2020). Translated into Maryland numbers, this means that 242,000 people are presently thinking of killing themselves, 40,333 will attempt suicide, and 1210 will die.

Suicide clusters and contagion are well established phenomena with documented connections to media coverage and publicity (Blasco-Fontecilla 2013). The Centers for Disease Control and the World Health Organization both promulgate guidelines for the media coverage of high profiles suicides (Carmichael 2019). These guidelines advise against the portrayal of self-destruction as a “brave,” or “romantic,” and discourage reports which idealize suicidal behavior. They also caution against explicit discussion of suicide methods. These recommendations were developed in part due to a study which demonstrated that deaths by helium asphyxiation increased by more than 400% in New York following publication of the book Final Exit in 1991 (Marzuk 1993).

Proponents of assisted suicide laws violate these public health recommendations when they describe self-destruction as a “graceful” or “beautiful” expression of personal autonomy (Death With Dignity 2020). To date there have been no well designed studies to clarify the relationship, if any, between adoption of assisted suicide laws and states rates of un-assisted suicide. However, following the highly publicized death of Brittany Maynard in 2014 the number of assisted deaths by lethal medication in Oregon nearly doubled, from 71 in 2013 to 132 in 2015 (Oregon 2015). In a letter to the Colorado Springs Gazette, Dr. Will Johnston documented the case of a young man who was inspired to research suicide methods online after being impressed by, and admiring, Brittany Maynard's suicide video (Johnston 2016).

Here in Maryland, two people with serious mental illness have sought psychiatric help to die on the basis of their mental illness. One was a resident of the Maryland state hospital system and made a request for lethal medication on the day the 2019 bill failed in the Senate (Hanson, personal communication). Another was a resident of the Eastern Shore with schizophrenia who contacted several forensic psychiatrists for a capacity assessment in order to apply for euthanasia in Switzerland (Neghi and Crowley, personal communications).

Adoption of this law carries serious implications for people with mental disorders who would demand equality under the law. People with serious and treatment-resistant eating disorders could qualify, since qualification is based upon prognosis rather than diagnosis.

2. Safeguard Failures

The Maryland Psychiatric Society considers the statutory safeguards to be inadequate. Furthermore, they historically have been ignored without consequences to the negligent physicians.

Between 1998 and 2012 a total of 22 Oregon physicians were referred to the Board of Medical Examiners for non-compliance with the provisions of the Death With Dignity Act. None could be sanctioned due to the “good faith” protections of the law, even when required witness attestations were missing. No attempt has been made by Oregon, or any independent researchers, to document unreported cases in Oregon since the entry into force of the DWDA. The true reporting rate in Oregon is therefore unknown (Lewis 2013).

Similarly, in the first year of the Colorado law all prescribing physicians attested that they followed the law even when 42 cases were missing the consultant's evaluation, 22 had no written request, and nine of 69 cases were not reported at all by the physician (Colorado 2017).

In 2016 the Des Moines Register investigated ten years of data in Washington and Oregon, and found that in 40% of cases the reports were missing key data.

Failure to submit required reports, or to hold physicians accountable for reporting failure, is a substantial weakness of this legislation. Even if all required documents were accounted for, there has been no study to date to confirm the accuracy and specificity of these statutory safeguards.

In Maryland, one physician was even willing to violate our state's criminal prohibition. The late Dr. Lawrence Egbert admitted participation in the assisted suicide deaths, by helium asphyxiation, of six non-terminally ill Maryland residents. Three of those patients had co-existing clinical depression. His actions were discovered purely by accident. He was never charged or prosecuted in Maryland. He admitted in an interview with the Baltimore Sun that he had been involved in 15 suicides in Maryland and 300 nationwide (Dance 2014).

If Maryland is unwilling to enforce criminal prohibitions, the enforcement of statutory safeguards is even less likely. Connecticut's Division of Criminal Justice acknowledged that the statutory construction of their legislation would have prohibited prosecution for murder (Connecticut 2015).

3. Implications for the Practice of Psychiatry

This legislation has the potential to significantly complicate the practice of psychiatry in Maryland, for both the treating clinician and when functioning as an evaluator of decision-making capacity.

This law would carve out a class of people who theoretically could be categorically exempt from emergency evaluation procedures or civil commitment. Given that some individuals live for more than one year after receiving a lethal prescription, and that capacity may deteriorate over that time, it is unclear whether a qualified patient who has lost capacity could be assessed and treated for mental illness under this law.

There is no provision to correct an error if lethal medication is given to a patient who has concealed his or her psychiatric history from a prescribing physician. A treating psychiatrist who discovers an error would have no legal means to take custody of or dispose of the medication given to a patient. There is no procedural mechanism to challenge a faulty or erroneous capacity assessment.

A psychiatrist charged with assessing capacity must also rule out the possibility of coercion. In order to do this, the evaluator must be at liberty to interview any individual with relevant information. Under this law, a coerced individual could refuse permission for the evaluator to speak with anyone who has knowledge of the coercion.

The law allows the patient to ingest the medication at the time and place of his or her choosing. Thus, a participating facility could require an inpatient psychiatric unit to allow ingestion on the ward in violation of ward suicide prevention policies. This would be particularly detrimental on units designed for the treatment of eating disorders or in geriatric units, where it would be most likely to occur. People with mental illness also develop co-occurring serious medical conditions such as diabetes; since the law does not require the patient to accept any treatment, this condition would qualify as “terminal” if the individual refuses insulin (Oregon Health Authority 2018). California's health department regulations mandate that state psychiatric facilities must carry out assisted suicides within their units under certain conditions (9 CCR §4601).

Conclusion

Several additional deficiencies have been identified by other opponent groups, and the Maryland Psychiatric Society endorses these concerns. These include:

1.  No requirement for decisional capacity at the time of ingestion.
2.  No requirement for an independent or law enforcement observer at the time of ingestion.
3.  No mechanism to detect a negligent, incompetent, or malicious prescriber.
4.  The risk to third parties in the home (depressed or mentally ill family members).
5.  Detrimental psychological effects on the involved medical professional.
6.  No requirement for a doctor to notify a power of attorney or guardian that a prescription has been requested.
7.  Potential federal civil rights violations if the eligible person is institutionalized in a correctional facility or state hospital where prevention of suicide is an affirmative obligation.
8.  The lack of mental health screening instruments validated in this population for this purpose.
9.  No mandatory reporting or whistleblower protection for healthcare providers aware of negligent or malicious prescribers

References:

Anfang S et al. APA Resource Document on Physician Assisted Death. American Psychiatric Association 2017.

Blasco-Fontecilla, Hilario. “On Suicide Clusters: More than Contagion.” The Australian and New Zealand Journal of Psychiatry 47, no. 5 (May 2013): 490–91. https://doi.org/10.1177/0004867412465023.

California. Petitions to the Superior Court and Access to the End of Life Option Act. 9 CCR §4601 (2016).

Carmichael, Victoria, and Rob Whitley. “Media Coverage of Robin Williams’ Suicide in the United States: A Contributor to Contagion?” PLOS ONE 14, no. 5 (May 9, 2019): e0216543. https://doi.org/10.1371/journal.pone.0216543.

Colorado End-of-Life Options Act, Year One 2017 Data Summary. Available at: https://drive.google.com/open?id=1kBXgAFzHl6kcfsvtLHfOQ94Unk9mDa-  Accessed February 2, 2020

Connecticut Division of Criminal Justice. Written Testimony Regarding HB7015. 2015. Available at https://www.cga.ct.gov/2015/JUDdata/Tmy/2015HB-07015-R000318-Division%20of%20Criminal%20Justice%20-%20State%20of%20Connecticut-TMY.PDF. Accessed February 4, 2020

Dance, Scott. 2014. “Maryland Strips Doctor of License for Assisting in Six Suicides - Baltimore Sun.” Baltimore Sun, December 30, 2014. https://www.baltimoresun.com/health/bs-hs-suicide-doctor-20141230-story.html.

Death with Dignity National Center. Stories. Available at: https://www.deathwithdignity.org/stories/  Accessed February 2, 2020.

Johnson, Will. 2016 “Brittany Maynard’s Story Sends the Wrong Message to Young People.” Accessed February 2, 2020. https://www.choiceillusioncolorado.org/2016/10/brittany-maynards-story-sends-wrong.html.

Lewis, Penney, and Isra Black. “Reporting and Scrutiny of Reported Cases in Four Jurisdictions Where Assisted Dying Is Lawful: A Review of the Evidence in the Netherlands, Belgium, Oregon and Switzerland.” Med Law Int 13, no. 4 (2013): 221–39.

Marzuk PM, Tardiff K, Hirsch CS, Leon AC, Stajic M, Hartwell N, Portera L (1993) Increase in suicide by asphyxiation in New York city after the publication of Final Exit. N Engl J Med 329:1508–1510.  https://doi.org/10.1056/NEJM199311113292022

Munson, Kyle, and Jason Clayworth. 2016. “Suicide with a Helping Hand Worries Iowans on Both Sides of ‘Right to Die.’” Des Moines Register, November 25, 2016. https://www.desmoinesregister.com/story/news/investigations/2016/11/25/too-weak-kill-herself-assistance-legal/92407392/.

Oregon. Death With Dignity Annual Reports. Available at: https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx Accessed February 2, 2020
Oregon Health Authority. 2018. Responses to Fabian Stahle. Available at: https://drive.google.com/file/d/1XopTDjBA2SAVBGBxpDazNN899eTHixSe/view. Accessed February 4, 2020

Shreiber, J, and L Culpepper. 2020. “Suicidal Ideation and Behavior in Adults.” Up-to-Date, January. https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults.