Suicide Prevention Researchers Leave Out Assisted Suicide

This article was published by National Review online on May 22, 2020.

Wesley Smith

By Wesley J Smith

It almost never fails. A learned article in a medical or bioethics journal laments our suicide crisis and urges greater efforts at prevention. And yet somehow, the authors never once mention the elephant in the room: i.e., the impact of ubiquitous suicide promotion by “death with dignity” activists, boosted by media commentators, in popular culture features, and as furthered by politicians.

It just happened again. An article published in the AMA’s JAMA Psychiatry: promises to “flatten the curve” of our rising suicide numbers, but doesn’t once mention assisted suicide as a contributor to the problem:

To drive this research agenda, we are acting on research that indicates suicide prevention efforts in health care settings have the potential to significantly reduce suicide rates. Nearly 30% of decedents had a health care visit in the 7 days before suicide; half were seen in health care settings within the preceding 30 days; and around 90% had visits in the year before death. Second, applying universal screening in the emergency care setting could double the number of individuals identified within usual care. 

Similarly, the application of risk prediction algorithms to electronic health records can enhance prediction of suicide attempts and deaths, particularly when the data are enriched with screening information. Third, there is a growing suite of effective interventions and care practices that include medications and psychotherapies, a brief safety plan intervention, and follow-up efforts at high-risk, critical points of care transition such as “caring communication” contacts, and telephone calls to encourage ongoing social connection and care engagement. These practices can improve function and reduce the frequency of suicide attempts between 30% to 50% over the following year. The NAASP recommends that these practices be combined in a system of care and that health care organizations strive for this “Zero Suicide” approach.

I’m all for it. But pretending assisted-suicide deaths are not “suicide,” as most laws require, doesn’t make them not suicide, and merely sweeps that aspect of our crisis under the rug.

Active suicide promotion for the ill and disabled is something new in our history. Unless suicide-prevention researchers include the impact of such advocacy in their studies, assess the consequences of the “some-suicides-are-good” message communicated by laws legalizing doctor-prescribed death, and explore the shameful failure of doctors and hospice professionals to call in prevention services when someone asks for help in dying where assisted suicide is legal, this will be for naught.

To paraphrase Lincoln, we can’t be half suicide prevention and half suicide promotion. Sooner or later, we will be all one or the other.

Suicide confusion: Suicide, assisted suicide and Covid-19.

This article was published by National Review online on May 12, 2020.

Wesley Smith

By Wesley J Smith

New Jersey recently became one of the seven states (plus the District of Columbia) to legalize assisted suicide by statute. In effect, New Jersey sanctions suicide for some residents through its public policy.

Now, with COVID-19, New Jersey officials are worried about a spike in suicide caused by the shutdown, so for them, suicide is bad. From the NJ.Com story:

On top of the more than 78,000 Americans who have already died from the fast-spreading virus, a new study from the Well Being Trust found conditions from the pandemic — including lost jobs, isolation, and fear over the future — could lead to 75,000 deaths in the nation from drug or alcohol abuse and suicide over the next decade.

This comes as a number of critics say they’re worried lockdowns designed to save lives from COVID-19 could have an even greater toll due to economic and mental despair.

[NJ Gov.] Murphy was asked Saturday during his daily coronavirus briefing in Trenton if the state will track suicides and consider this when determining how to reopen the state. “I don’t know specifics in terms of tracking suicides, but we have said this: The combination of isolation and now other factors like job losses are having big impacts on folks, there’s no question about it,” the governor said.

So, let me get this straight. If someone is in despair because they lost everything when their business collapsed or had a loved one die from COVID-19, they shouldn’t be able to commit facilitated suicide.

But if they are in despair because they have been diagnosed as terminally ill with COVID-19, they should not only be able to self-terminate, but also, have their suicide facilitated by a doctor under a law signed by Governor Murphy.

No! That’s nonsensical. Governor Murphy should be concerned about preventing all suicides, not just some.

Suicidal ideation is suicidal ideation — regardless of the reason for wanting to die. Everyone who becomes suicidal because of a COVID-19 impact — or for any other reason — should receive prevention services. Everyone. It is illogical and destructive to the value of human life for New Jersey (and other pro–assisted suicide states) to have such a lethally dichotomous public policy.

Conceiving the inconceivable: assisted suicide for people with mental illness.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Thank you to Dr Mark Komrad for sharing this superb paper by Bernardo Carpiniello published in the Journal of the Italian Society of Psychiatry. Carpiniello works in the Department of Medical Sciences and Public Health-Unit of Psychiatry, University of Cagliari Italy.

Carpiniello's paper - Conceiving the unconceivable: ethical and clinical concerns over assisted suicide for people with mental disorders is a significant paper dealing with the concerns related to euthanasia for psychiatric reasons. 

Carpiniello recognizes that only a few jurisdictions in the world have legalized euthanasia and assisted suicide and in these jurisdictions only a small number of these deaths done to people with mental illness. 

Carpiniello points out that only 34% of Dutch physicians will participate in euthanasia for mental disorders.

Polling data indicates that there is more opposition by Dutch psychiatrists to psychiatric euthanasia with 53% of psychiatrists opposed to euthanasia for mental illness in 1995 and 63% in 2015. He suggests that the drop in support for psychiatric euthanasia is related to moral distress. He states:

Euthanasia or assisted suicide represents a typical example of a situation in which psychiatrists are faced with the impossibility of having to reconcile two moral obligations, a duty of care and respect of patient autonomy. To put it bluntly, for many psychiatrists euthanasia is ethically unacceptable, particularly as the main aim of psychiatry is to limit patients’ suffering.

Carpiniello then points out the position of the American Psychiatric Association.

“the American Psychiatric Association, in concert with the American Medical Association’s position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death”

Carpiniello expresses his concern for the growth of euthanasia in countries where it is legal.

Euthanasia has been reported as a typical example of the “slippery slope, down which we have rolled to now allow something that was impossible to conceive as ever being acceptable”

Based on the increase in the number of euthanasia deaths and the expansion of acceptable reasons for euthanasia, I agree that incremental extensions will occur, if legalized.

Carpiniello tackles the question of suicide prevention, a primary public health concern. He quotes from the WHO Director-General, Tedros Adhanom Ghebreyesus stated:

“despite progress, one person still dies every 40 seconds from suicide. Every death is a tragedy for family, friends and colleagues. Yet suicides are preventable. We call on all countries to incorporate proven suicide prevention strategies into national health and education programmes in a sustainable way”

Carpiniello indicates that suicide prevention and suicide assistance are irreconcilable.

Indeed, an emphasis on suicide prevention from a public health perspective seems to be somewhat hard to reconcile ...for those countries simultaneously equipped with social and health policies established for the specific purpose of preventing suicide. Considering the specific role of psychiatry in preventing suicide, put in very simple terms the question is: what is the point of psychiatrists trying in every way possible to prevent suicide if the person concerned is entitled by law to seek assistance to commit this action?

Carpiniello examines the clinical concerns related to psychiatrists approving euthanasia. He points out:

“assessments of competency, sustained wish to die prematurely, depressive disorder, demoralization and ‘unbearable suffering’ in the terminally ill are clinically uncertain and difficult tasks ... As yet psychiatry does not have the expertise to ‘select’ those whose wish for hastened death is rational, humane and ‘healthy’

He explains that there are no objective measures to determine if someone has lasting or unbearable suffering.

Further to that Carpiniello finds that it is impossible to determine if treatment is futile for the patient. He states:

How can we confirm that a single case should definitely be considered untreatable if “there are no universal standards defining incurability in most cases of mental illness” and “there is no reliable mechanism to define incurable disease and determine medical futility for psychiatric care

He points out that there is no definition for the condition known as treatment resistant depression (TRD). He states:

it could prove an arduous task, even for the most experienced psychiatrist, to confirm that the case undergoing evaluation for assisted suicide is an actual TRD, ...Accordingly, it should be kept in mind how approx. 20% of Dutch patients requesting euthanasia had never undergone psychiatric hospitalization, 56% had refused some form of recommended treatment, and how in 27% of cases patients had requested assistance with dying from a physician who had not previously been involved in their treatment.

He continues by quoting from a study indicating that the majority of TRD patients get better.

More recently, 155 TRD patients were evaluated over a 1-7 year (median 36 months) follow-up, revealing how 39.2% of follow-up months were asymptomatic and 21.1% at sub-threshold symptom level, while 15.8% featured a mild, 13.9% moderate, and 10.0% severe depressive episode level, thus demonstrating how the majority of patients with TRD manage to achieve an asymptomatic state.

Further to that, he shows how there is no standard to assess competence or decisional capacity amongst these patients. He quotes from a study that was based on information from the Dutch Regional Review Committees that found:

in their evaluations physicians frequently stated that psychosis or depression did (or did not) affect capacity but provided little explanation to corroborate their opinions. The findings of this study once again raised a series of doubts as to the reliability of evaluation of decisional capacity of patients requesting EAS, at least in the Netherlands.

He then examines the phenomenon of transference and countertransference that exists in a therapeutic relationship with a patient and he states:

Some authors have criticized the assumption according to which a physician will always act in the interests of their patients, mostly because it fails to consider the doctor’s unconscious, and at times conscious, desire for the patient to die and alleviate distress for all concerned, including the physician. ...Doctors who are affected by countertransference or who have psychologically committed themselves to PAS may be prone to accepting patients’ reasons for PAS at face value without thorough exploration”

He then explains how physician/patient relationships can lead to pseudoempathy. He states:

One of the most frequently cited consequences of countertransference is over-identification with the patient, giving rise to a so-called ‘pseudoempathy’, a condition resulting in the physician experiencing the feeling that the patient’s suicidalwish is ‘normal’ and that they would feel the same way.

Carpiniello examines what he calls, the undesiralbe consequences of assisted suicide. He sites several concerns including:

• “... will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients? If so, how far will the influence of that belief spread?”
• data from the Netherlands, reports “56% of cases in which social isolation or loneliness was important enough to be mentioned in the report”, arguing that “the latter evokes the concern that physician assisted death served as a substitute for effective psychosocial intervention and support”
• EAS in psychiatric patients may be detrimental in the advancement of research and implementation of new treatments, given that it “may reinforce poor expectations of the medical community for mental illness treatment and contribute to a relative lack of progress in developing more effective therapeutic strategies” 
• “What consequences on social representations of mental illnesses, on how to deal with a mental illness and on professional profile if psychiatrists recognize that life with mental illness – even if “only” in individual cases – is not worth living?

Carpiniello concludes that no firm conclusions can be drawn based on data related to euthanasia for psychiatric reasons.

Carpiniello's paper clearly indicates that the negative consequences related to euthanasia for mental disorders suggest that this should not be done.

Margaret Dore: New Jersey Motion for Reconsideration, on assisted suicide law.

This article was published by Choice is an Illusion on April 24, 2020.

Previous articles:

1. New Jersey euthanasia act must be set-aside (Link).
2. New Jersey appellate court lifts restraining order that stopped assisted suicide (Link).
3. Court order temporarily stops assisted suicide in New Jersey (Link).

Margaret Dore

To view Dore's brief as submitted, click here.

I. RELIEF REQUESTED

Margaret Dore moves for reconsideration of the Court’s order dated April 1, 2020, which upheld the constitutionality of the Medical Aid in Dying for the Terminally Ill Act.[1]

II. THE ACT MUST BE SET ASIDE

The Court did not reach the Act’s violation of the object in title rule, which is dispositive to set the Act aside. The Court should reach this issue now to overturn the Act.

The Court’s order states that Dore asked the Court to declare the Act unconstitutional “on grounds not asserted by plaintiffs.”[2] The plaintiffs, did, however, ask the Court to rule on the issue, stating:

Ms. Dore’s brief should be considered by the Court since if the law is unconstitutional under the single object rule, it should be the Court’s responsibility to raise that issue sua sponte even if not raised by Ms. Dore or the Plaintiffs.[3]

The Legislature understood that it was enacting a strictly voluntary law limited to assisted suicide for dying patients.[4] The prior judge expressed a similar view. See, for example, the transcript from the hearing on August 14, 2019 (“This case is not about euthanasia”).[5]

This case, however, is about euthanasia. The Act is also not limited to dying people. Patient voluntariness is allowed, but not required. These are material facts not disclosed by the Act’s title and related findings. The Act is unconstitutional and must be set aside.

III. WHAT THE ACT DOES

A. The Act Allows Physician-Assisted Suicide, Which It Terms Medical Aid in Dying

Dictionary definitions of “assisted suicide,” include “suicide committed by someone with assistance from another person especially: physician-assisted suicide.”[6] Dictionary definitions of physician-assisted suicide include the following:

[S]uicide by a patient facilitated by means (such as a drug prescription) or by information (such as an indication of a lethal dosage) provided by a physician aware of the patient's intent.[7]

Here, the Act allows this same practice, which it terms medical aid in dying. The Act, “Findings, Declarations Relative to Medical Aid in Dying for the Terminally Ill,” states:

[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[8]

The Act also specifically describes physician involvement to write the prescription for the lethal dose.[9] The bottom line, the Act allows physician-assisted suicide as traditionally defined, which it terms medical aid in dying.

B. The Act Legalizes Assisted Suicide as a “Right”

Again, the Act states:

[T]his State affirms the right of a qualified terminally ill patient, protected by appropriate safeguards, to obtain medication that the patient may choose to self-administer in order to bring about the patient’s humane and dignified death. (Emphasis added).[10]

If for the purpose of argument, this provision is limited to allowing voluntary assisted suicide (because it says that the patient may chose to self-administer the lethal medication), the Act will nonetheless also allow euthanasia due to assisted suicide being described as a “right.” This is true due to: (1) The New Mexico Supreme Court Decision, Morris v. Brandenburg, 376 P.3d 836 (2016); and (2) the Americans with Disability Act, both of which are discussed below.

1. Morris v. Brandenburg

The 5-0 decision states in part:

[W]e agree with the legitimate concern that recognizing a right to physician aid in dying will lead to voluntary or involuntary euthanasia because if it is a right, it must be made available to everyone, even when a duly appointed surrogate makes the decision, and even when the patient is unable to self-administer the life-ending medication. (Emphasis added).[11] 

2. The Americans With Disabilities Act (ADA)

The ADA is “a federal civil rights law that prohibits discrimination against individuals with disabilities in every day activities, including medical services.”[12] “Medical care providers are required to make their services available in an accessible manner.”[13]This includes:

Reasonable modifications to policies, practices, and procedures to make healthcare services fully available to individuals with disabilities, unless the modifications would fundamentally alter the nature of the services (i.e., alter the essential nature of the services). (Emphasis added).[14]

Here, the Act legalized “medical aid in dying” as part of New Jersey healthcare.[15] If for the purpose of argument, the Act does in fact require self-administration, the ADA will require a reasonable accommodation for individuals unable to self-administer. This will mean administration by another person. The Act will thereby require euthanasia as traditionally defined.

IV. HOW THE ACT WORKS

The Act has an application process to obtain the lethal dose.[16] Once the lethal dose is issued by the pharmacy, there is no oversight.[17] No witness, not even a doctor, is required to present at the death.[18]

V. “ELIGIBLE” PERSONS MAY HAVE YEARS TO LIVE

The Act applies to “terminally ill” individuals. The Act states:

“Terminally ill” means that the patient is in the terminal stage of an irreversibly fatal illness, disease, or condition with a prognosis, based upon reasonable medical certainty, of a life expectancy of six months or less.[19]

Such persons may, in fact, have years or decades to live. This is true due to actual mistakes (the test results got switched), and because predicting life expectancy is not an exact science.[20] Also, sometimes doctors are wrong, as in way wrong.

Consider John Norton, diagnosed with ALS at age 18.[21] He was told that he would get progressively worse (be paralyzed) and die in three to five years.[22] Instead, the disease progression stopped on its own.[23] In a 2012 affidavit, at age 74, he states:

If assisted suicide or euthanasia had been available to me in the 1950's, I would have missed the bulk of my life and my life yet to come.[24]

VI. ELDER ABUSE

A. Elder Abuse Is a Problem in New Jersey; Perpetrators Are Often Family Members

Elder abuse is a problem in New Jersey and throughout the United States.[25] Nationwide, prominent cases include actor Mickey Rooney and New York philanthropist, Brooke Astor.[26]

Perpetrators are often family members.[27] They typically start out with small crimes, such as stealing jewelry and blank checks, before moving on to larger items or to coercing victims to change their wills or to liquidate their assets.[28] Amy Mix, of the AARP Legal Counsel of the Elderly, states:

[Perpetrators] are family members, lots are friends, often people who befriend a senior through church .... We had a senior victim who had given her life savings away to some scammer who told her that she’d won the lottery and would have to pay the taxes ahead of time.... The scammer found the victim using information in her husband’s obituary.[29] 

B. Elder Abuse Is Rarely Reported, Victims Don’t Want to Report Their Children as Abusers

The vast majority of elder abuse cases are not reported to the authorities. Reasons include:

[F]ear of retaliation, lack of physical and/or cognitive ability to report, or because they don’t want to get the abuser (90% of whom are family members) in trouble. (Emphasis added).[30] 

C. Elder Abuse Is Sometimes Fatal

In some cases, elder abuse is fatal. More notorious cases include California’s “black widow” murders, in which two women took out life insurance policies on homeless men.[31] Their first victim was 73 year old Paul Vados, whose death was staged to look like a hit and run accident.[32] The women collected $589,124.93.[33]

Consider also, People v. Stuart in which an adult child killed her mother with a pillow, so as to inherit. The Court observed:

Financial considerations [are] an all too common motivation for killing someone.[34]

VII. PENALTIES PROVIDE A DETERRENT; NOT THE ACT

While elder abuse is a largely uncontrolled problem, there are penalties for doing it and when perpetrators are caught, they can be punished. The California black widows and the adult child who killed her mother with a pillow, discussed above, served prison time. With a risk of punishment, there is a deterrent to protect other potential victims from harm.

This is in contrast to the Act, in which purported protections are illusory, which renders potential victims sitting ducks to their adult children and other predators, without recourse. See below.

VIII. THE ACT IS STACKED AGAINST THE INDIVIDUAL

A. “Even If a Patient Struggled, Who Would Know?”

The Act has no oversight over administration of the lethal dose.[35] In addition, the drugs used are water and alcohol soluble, such that they can be injected into a sleeping or restrained person without consent.[36] Alex Schadenberg, Executive Director for the Euthanasia Prevention Coalition, puts it this way:

With assisted suicide laws in Washington and Oregon [and with the Act], perpetrators can . . . take a “legal” route, by getting an elder to sign a lethal dose request. Once the prescription is filled, there is no supervision over administration. Even if a patient struggled, “who would know?” (Emphasis added).[37] 

B. Someone Else Is Allowed to Communicate on the Patient’s Behalf

The Act uses the word, “capable,” which is specially defined to allow other people to communicate on the patient’s behalf, as long as they are “familiar with the patient’s manner of communicating.” The Act states:

“Capable” means having the capacity to make health care decisions and to communicate them to a health care provider, including communication through persons familiar with the patient’s manner of communicating if those persons are available. (Emphasis added).[38]

Being familiar with a patient’s manner of communicating is a very minimal standard. Consider, for example, a doctor’s assistant who is familiar with a patient’s “manner of communicating” in Spanish, but she herself does not understand Spanish. That, however, would be good enough for her to communicate on the patient’s behalf during the lethal dose request process. The patient would not necessarily be in control of his or her fate.

C. Purported Protections Are Illusory

The Act says that the attending physician is to ensure that all “appropriate” steps are carried out in “accordance” with the Act as necessary. The Act states:

The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] . . . including such actions as are necessary to: . . . 

(6) recommend that the patient participate in a consultation concerning concurrent or additional treatment opportunities . . . [and] 

(8) inform the patient of the patient’s opportunity to rescind the request . . . . (Emphasis added).[39]

The Act does not define "appropriate" or “accordance.”[40] Dictionary definitions of appropriate include "suitable or proper” in the circumstances.[41] Dictionary definitions of accordance include “in the spirit of,” meaning “in thought or intention.”[42]

With these definitions, the attending physician’s view of what is "suitable or proper" is enough for compliance with patient protections. The physician's "thought or intention" is similarly sufficient. The purported protections are neutralized to whatever an attending physician happens to feel is appropriate and/or had a thought or intention to do. The “protections” are unenforceable.

D. Deaths in Accordance With the Act Are “Natural” as a Matter of Law 

1. Action taken in accordance with the Act is not suicide or homicide

The Act states:

Any action taken in accordance with the provisions of [the Act] shall not constitute patient abuse or neglect, suicide, assisted suicide, mercy killing, euthanasia, or homicide under any law of this State. (Emphasis added).[43] 

2. The Act requires deaths to be reported as “natural”

In New Jersey, death certificates have five categories for reporting the manner of death, four of which are substantive: (1) natural; (2) accident; (3) suicide; and (4) homicide.[44] The fifth category is “undetermined.”[45]

As noted in the preceding section, a death occurring in accordance with the Act does not constitute suicide or homicide under any law of the State. The death is also not an accident due its having been an intended event. This leaves “natural.” Deaths occurring pursuant to the Act are natural as a matter of law.

E. Dr. Shipman and the Call for Death Certificate Reform

Per a 2005 article in the UK’s Guardian newspaper, there was a public inquiry regarding Dr. Harold Shipman, which determined that he had “killed at least 250 of his patients over 23 years.”[46] The inquiry also found:

that by issuing death certificates stating natural causes, the serial killer [Shipman] was able to evade investigation by coroners. (Emphasis added). [47]

Per a subsequent article in 2015, proposed reforms included having a medical examiner review death certificates, so as to improve patient safety.[48] The New Jersey Act has instead moved in the opposite direction to require that deaths be reported as natural. Doctors and other perpetrators have been enabled to kill under mandatory legal cover.

F. The Act Renders New Jersey Residents Sitting Ducks to Their Heirs and Other Predators

New Jersey’s slayer statute prevents a killer from inheriting from his or her victim. The statute states:

[A]n individual who is responsible for the intentional killing of the decedent forfeits [his or her inheritance].”[49]

The rational is that a criminal should not be allowed to benefit from his or her crime.[50]

Under the Act, however, a person who intentionally kills another person is allowed to inherit. This is due to the deaths being certified as natural. With the passage of the Act, New Jersey residents with money, meaning the middle class and above, have been rendered sitting ducks to their heirs and other predators.

IX. OTHER CONSIDERATIONS

A. My Clients Suffered Trauma in Oregon and Washington State

I have had two cases where my clients suffered trauma due to legal assisted suicide. In the first case, one side of my client’s family wanted her father to take the lethal dose, while the other side did not. The father spent the last months of his life caught in the middle and torn over whether he should kill himself. My client was severely traumatized. The father did not take the lethal dose and died a natural death.

In the other case, my client’s father died via the lethal dose at a suicide party. It’s not clear, however, that administration of the lethal dose was voluntary. A man who was present told my client that his father had refused to take the lethal dose when it was delivered, stating: "You're not killing me. I'm going to bed." The man also said that my client’s father took the lethal dose the next night when he (the father) was already intoxicated on alcohol. The man who told this to my client subsequently changed his story.

My client, although he was not present, was traumatized over the incident, and also by the sudden loss of his father.

B. In Oregon, Other Suicides Have Increased with Legalization of Physician-Assisted Suicide

Government reports from Oregon show a positive correlation between the legalization of physician-assisted suicide and an increase in other (conventional) suicides. This correlation is consistent with a suicide contagion in which legalizing physician-assisted suicide encouraged other suicides.[51]

C. The Felony for Undue Influence Is Illusory

The Act has a felony for “undue influence,” which is not defined and has no elements of proof. The Act merely states:

A person who . . . exerts undue influence on a patient to request medication pursuant to [the Act] or to destroy a rescission of a request is guilty of a crime of the third degree. (Emphasis added).[52]

The Act also specifically allows conduct normally used to prove undue influence. For example, the Act allows an infirm person with a terminal disease to request the lethal dose. Physical weakness is a factor generally used to PROVE undue influence.[53]

How do you prove that undue influence occurred when the Act does not define it, and the Act also allows conduct generally used to prove it? You can’t. The felony for undue influence is illusory and unenforceable.

X. THE ACT VIOLATES THE OBJECT IN TITLE RULE

As noted supra, the New Jersey Constitution governs permissible legislative conduct when enacting legislation. To that end, the Constitution sets forth the object in title rule, as follows:

To avoid improper influences which may result from intermixing in one and the same act such things as have no proper relation to each other, every law shall embrace but one object, and that [object] shall be expressed in the title. (Emphasis added).[54]

The rule is designed to protect against the misleading of the people. State v Guida, 119 N.J.L. 464, 465-466 (1938), states:

The sole requirement is that [the title] ‘shall express its object in a general way so as to be intelligible to the ordinary reader’; and it is the settled rule that a statute will not be judicially declared inoperative and unenforceable on this ground unless the deficiency plainly exists. (Emphasis added).

In the case at bar, the deficiency plainly exists. The Legislature, the Attorney General and the prior court were all mislead by the Act’s deceptive title, implying that the Act is limited to voluntary assisted suicide, when the Act also allows non-voluntary euthanasia. This Court has also been mislead. The Act must be set aside.

Respectfully submitted this 18th day of April 2020

Margaret Dore Esq., MBA, appearing pro se
Law Office of Margaret K. Dore, PS
1001 4th Avenue, Suite 4400
Seattle, WA 98154
206 697 1217

Footnotes:

[1] The Act is attached in the brief's appendix, at pages A-1 to A-15.
[2] The Order, page 35, attached in the brief's appendix, at page A-20.
[3] Letter from E. David Smith, Esq., to Judge Lougy, dated March 20, 2020, in the brief's appendix at page A-23.
[4] See for example, the Order on Emergent Motion, Superior Court of New Jersey Appellate Division, August 27, 2019 (“the process is entirely voluntary on the part of all participants, including patients...”). Attached in the brief's appendix at page A-63.
[5] Transcript attached in the brief's appendix at page A-62.
[6] Merriam-Webster, attached in the brief's appendix at page A-27; https://www.merriam-webster.com/dictionary/assisted%20suicide?utm_campaign=sd&utm_medium=serp&utm_source=jsonld
[7] Merriam-Webster, attached in the brief's appendix at page A-28.
[8] The Act, Section C.26:16-2, attached in the brief's appendix at page A-1.
[9] The Act, Section C.26:16-6, states:

The attending physician shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] before writing a prescription for medication that a qualified terminally ill patient may choose to self-administer pursuant to [the Act]. (Attached in the brief's appendix at page A-4).

[10] The Act, page 1, attached in the brief's appendix at page A-1
[11] Morris v. Brandenburg, 376 P.3d 836, 848 (2016).
[12] U.S. Department of Justice, Civil Rights Division, and the U.S. Department of Health and Human Services, Office for Civil Rights, “Americans with Disabilities Act: Access to Medical Care for Individuals with Mobility Disabilities,” July 2010, available at https://www.ada.gov/medcare_mobility_ta/medcare_ta.htm
[13] Id.
[14] Id.
[15] The Act, Findings, attached in the brief's appendix at page A-1.
[16] See the Act, attached in the brief's appendix at pp. A-3 to A-7.
[17] See the Act in its entirety, in the brief's appendix at pp. A-1 to A-15.
[18] Id.
[19] The Act, C.26:16-3, attached in the brief's appendix at page A-3.
[20] Cf. Jessica Firger, "12 Million Americans Misdiagnosed Each Year," CBS NEWS, April 17, 2014, attached in the brief's appendix at page A-29; and Nina Shapiro, "Terminal Uncertainty — Washington's New 'Death with Dignity' Law Allows Doctors to Help People Commit Suicide — Once They've Determined That the Patient Has Only Six Months to Live. But What If They're Wrong?,” The Seattle Weekly, 01/14/09, attached in the brief's appendix at pages A-30 to A-33.
[21] Affidavit of John Norton, attached in the brief's appendix at pages A-34 to A-36.
[22] Id., ¶ 1.
[23] Id., ¶ 4.
[24] Id., ¶ 5.
[25] See e.g., Dansky Katz Ringold York, Attorneys at Law, Marlton New Jersey, “How to Spot and Prevent Elder Financial Abuse,” April 27, 2016, at https://njlegalhelp.com/how-to-spot-and-prevent-elder-financial-abuse; and Beth Fitzgerald, “New Jersey Considers Law to Prevent ‘Granny Snatching,’” New Jersey Spotlight, MAY 21, 2012, http://www.njspotlight.com/stories/12/0520/2037/
[26] Tom Cohen, “Mickey Rooney tells [U.S.] Senate panel he was a victim of elder abuse,” CNN, March 2, 2011; Carole Fleck, “Brooke Astor’s Grandson Tells Senate Panel of Financial Abuse,” AARP Bulletin Today, 02/05/2015 (“The grandson of socialite Brooke Astor, who blew the whistle on his father for plundering millions from his grandmother’s estate, told the Senate panel Wednesday that his grandmother’s greatest legacy may be the national attention focused on elder financial abuse.”), and Matthew Talbot, “Issues of Prosecuting Elder Abuse: The Casey Kasem Case,” Talbot Law Group, PC, January 4, 2016, available at
https://www.linkedin.com/pulse/issues-prosecuting-elder-abuse-casey-kasem-case-matthew-talbot
[27] Id., MetLife Mature Market Institute, “Broken Trust: Elders, Familyand Finances, A Study on Elder Abuse Prevention,” March 2009, at  http://www.metlife.com/assets/cao/mmi/publications/studies/mmi-broken-trust.pdf
[28] Id.
[29] Kathryn Alfisi, “Breaking the Silence on Elder Abuse,” Washington Lawyer, February 2015.
[30] “Adult Protective Services: Facts and Fiction,” Division of Aging Services, NJ Department of Human Services, available at
http://www.nj.gov/humanservices/dmahs/home/Adult_Protective_Services_Training.pdf
[31] See People v. Rutterschmidt, 55 Cal.4th 650 (2012). See also  https://en.wikipedia.org/wiki/Black_Widow_Murders
[32] Rutterschmidt, at 652-3.
[33] Id. at 652.
[34] 67 Cal.Rptr.3d 129, 143 (2007), available at
https://www.leagle.com/decision/200719667calrptr3d1291182
[35] See the Act in its entirety, attached in the brief's appendix at A-1 to A-15.
[36] The drugs used include Secobarbital, Pentobarbital and Phenobarbital, which are water and/or alcohol soluble. See excerpt from Oregon’s and Washington’s annual reports, attached hereto at A-41 & A-42 (listing these drugs). See also http://www.drugs.com/pr/seconal-sodium.html,  http://www.drugs.com/pro/nembutal.html and
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2977013
[37] Alex Schadenberg, Letter to the Editor, “Elder abuse a growing problem,” The Advocate, Official Publication of the Idaho State Bar, October 2010, page 14.
[38] The Act, C.26:16-3, attached in the brief's appendix at page A-2.
[39] Attached in the brief's appendix at page A-4.
[40] See the Act in its entirety, attached in the brief's appendix at pages A-1 through A-15.
[41] Attached in the brief's appendix at page A-43.
[42] Attached in the brief's appendix at pages 44 and A-45.
[43] The Act, C.26:16-17.a.(2), attached in the brief's appendix at page A-9.
[44] Andrew L. Falzon, MD, and Sindy M. Paul, MPH, “Death Investigation and Certification in New Jersey,” MD Advisor, a journal for the New Jersey medical community, 2016. (Attached in the brief's appendix at page A-46).
[45] Id.
[46] David Batty, “Q & A: Harold Shipman,” The Guardian, 08/25/05, at https://www.theguardian.com/society/2005/aug/25/health.shipman. (Attached in the brief's appendix at pages A-47 to A-49).
[47] Id., attached in the brief's appendix at page A-49.
[48] Press Association, “Death Certificate Reform Delays ‘Incomprehensible,”
The Guardian, January 21, 2015, attached in the brief's appendix at pages A-50 to A-51.
[49] NJ Rev Stat § 3B:7-1.1, attached in the brief's appendix at pages A-52 and A-53.
[50] Cf. Ilene S. Cooper and Jaclene D'Agostino, "Forfeiture and New York's 'Slayer Rule', NYSBA Journal, March/April 2015, attached in the brief's appendix at page A-54.
[51] For a more information, see Margaret Dore, “In Oregon, Other Suicides Have Increased with Legalization of Assisted Suicide,” August 18, 2017, attached in the brief's appendix at pages A-55 to A-57. See also the Declaration of Williard Johnston, MD, attached in the brief's appendix at pages A-58 to A-60.
[52] Attached in the brief's appendix at page A-10.
[53] Cf. Neugebauer v. Neugebauer, 804 N.W.2d 450, ¶17 (2011)(“physical . . . weakness is always material upon the question of undue influence”).

The Covid-19 crisis has led to more cultural loneliness. Have you called your mom today?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

I have published several articles about the epidemic of loneliness and isolation and how it effects the physical and psychological health of people. Loneliness and isolation also leads to requests for assisted death.

• Loneliness is an epidemic among seniors that requires a caring response. 
• Loneliness is an epidemic that can be detrimental to your health.  
• Being with others cures the epidemic of loneliness.  
• Suicide epidemic exacerbated by loneliness.

A British study found that 22% of seniors, over the age of 65 will talk to only three or fewer people per week. A September 7, 2019 article in studyfinds.org reported:

According to the survey of 1,896 seniors over 65 in the United Kingdom, more than one in five (22%) will have a conversation with no more than just three people over the span of an entire week! That translates to nearly 2.6 million elderly folks who don’t enjoy regular human contact on a daily basis. Perhaps most alarming though is researchers say an alarming 225,000 individuals will go a week without talking to anyone face-to-face.

We can reduce the scourge of suicide and the cultural abandonment associated with assisted death, by caring for and being with others at their time of need. It is essential that people who feel that their life lacks value or purpose, or feel that no one cares, is offered purpose, support and genuine hope from their significant community.

The Covid-19 crisis and social distancing has led to more loneliness and social isolation.

One answer is to call your friends and family. A call to your family and friends can make a difference. Some families are communicating by video over the internet. This is an excellent way to communicate with others.

Your call may be the only call that your mother receives today.

Oregon’s Suicide Crisis Worsens

This article was published by the National Review online on March 5, 2020.

Wesley Smith

By Wesley J Smith

Oregon, a state that has considerably liberalized its assisted-suicide laws, has an ongoing youth and general suicide crisis on its hands. From an Oregon Health Authority press release:

In February the Centers for Disease Control and Prevention released data showing that suicide was the leading cause of death among Oregon youth ages 10 to 24 in 2018, up from the second leading cause of death in 2017. Oregon is now ranked 11th highest in the nation for youth suicide death rates (up from 17th in 2017). 

The change in rank is due to multiple factors: There was a rise in the suicide rate as well as a drop in the rate of unintentional injury deaths, the former leading cause. The unintentional injury category includes overdose deaths and motor vehicle accidents. While the suicide rate has increased, the unintentional injury rate decreased from 2017 to 2018. 

“Suicide continues to be a concerning problem in Oregon across all age groups, including youth, as this new data confirms,” said Dana Hargunani, Oregon Health Authority’s chief medical officer. “We continue to prioritize work across Oregon to support young people in schools, at home and in our communities. Fortunately, we are able to apply best practices that work to prevent suicide, and there are many ways you can get involved.”

Of course, the state’s suicide numbers exclude the thousands of people who have died from assisted suicide since 1997, and state public-health bureaucrats remain clueless of the possibility that allowing assisted suicide for one group of people might give others the idea that self-killing is a splendid way to end suffering.

The OHA has conflicting mandates when it comes to suicide: promoting it for the sick while striving to prevent it among the young and others. Sorry, that’s not how life works.

Assisted suicide goes against our values

This opinion article was published by the Concord Monitor on February 11, 2020

By Steven Wade
Executive Director of the Brain Injury Association

House Bill 1659 effectively gives physicians permission to prescribe drugs that result in patient suicide. We have serious concerns about the potential impact on New Hampshire’s at-risk population if this bill passes. It normalizes suicide as medical care and corrupts the doctor/patient relationship.

New Hampshire suicide rates are up nearly 50% over the past 10 years. New laws have been passed recently to beef up suicide prevention efforts because there are populations, including veterans, teens, people with disabilities, brain injury survivors and the elderly “pre-disposed” to suicide for reasons including depression, lack of autonomy and inability to engage in activities that make life enjoyable.

New Hampshire has a suicide crisis and has set an ambitious goal of zero suicides. This bill works against that goal. What sort of a message does it send to at-risk people if New Hampshire passes a law that says suicide is an easily achieved option?

The exploitation of the elderly is another significant problem in New Hampshire. This bill could enable exploiters to misuse the law to the detriment of those dependent on others for their care. Anyone with ulterior motives like convenience and cost will have the power to steer vulnerable members of our society – who are not necessarily dying – in the direction of death instead of care. Instead the state should be investing in greatly expanded access to palliative care and mental health services for those at-risk populations relying on the state for their care.

This bill calls into question the state’s power to set standards for quality of life. If it’s a terminal illness predicted to last six months now, what might it become in the future? Laws like this inevitably expand over time. If New Hampshire opens the door to assisted suicide, we will have to face whatever might be on the other side of that door.

HB 1659 goes against the very essence of who we are as citizens of New Hampshire. If we want to show that we value the lives of at-risk teens, the elderly, people with disabilities and veterans who have fought for our country, we should be focusing our energy on providing them with care, not with death.

(Steven Wade is the executive director of the Brain Injury Association of New Hampshire in Concord and a member of the N.H. Coalition Against Assisted Suicide.)

US Congress Resolution H.Con.Res.79: Assisted suicide puts everyone at risk of deadly harm.

(Link to the Congressional Resolution H.Con.Res.79)

Expressing the sense of the Congress that assisted suicide (sometimes referred to using other terms) puts everyone, including those most vulnerable, at risk of deadly harm.

IN THE HOUSE OF REPRESENTATIVES
December 12, 2019

Mr. Correa (for himself, Mr. Wenstrup, Mr. Peterson, Mr. Smith of New Jersey, Mr. Langevin, Mrs. Wagner, Mr. Lipinski, Mr. LaHood, Mr. Cartwright, Mr. Harris, and Mr. Abraham) submitted the following concurrent resolution; which was referred to the Committee on Energy and Commerce.

Whereas “suicide” means the act of intentionally ending one’s own life, preempting death from disease, accident, injury, age, or other condition;

Whereas “assisting in a suicide”, sometimes referred to as death with dignity, end-of-life options, aid-in-dying, or similar phrases, means knowingly and willingly prescribing, providing, dispensing, or distributing to an individual a substance, device, or other means that, if taken, used, ingested, or administered as directed, expected, or instructed, will, with reasonable medical certainty, result in the death of the individual, preempting death from disease, accident, injury, age, or other condition;

Whereas society has a longstanding policy of supporting suicide prevention such as through the efforts of many public and private suicide prevention programs, the benefits of which could be denied under a public policy of assisted suicide;

Whereas assisted suicide most directly threatens the lives of people who are elderly, experience depression, have a disability, or are subject to emotional or financial pressure to end their lives;

Whereas the Oregon Health Authority’s annual reports reveal that pain or the fear of pain is listed second to last (25 percent) among the reasons cited by all patients seeking lethal drugs since 1998, while the top 5 reasons cited are psychological and social concerns: “losing autonomy” (92 percent), “less able to engage in activities that make life enjoyable” (90 percent), “loss of dignity” (79 percent), “losing control of bodily functions” (48 percent), and “burden on family friends/caregivers” (41 percent);

Whereas the Supreme Court has ruled twice (in Washington v. Glucksberg and Vacco v. Quill) that there is no constitutional right to assisted suicide, that the Government has a legitimate interest in prohibiting assisted suicide, and that such prohibitions rationally relate to “protecting the vulnerable from coercion” and “protecting disabled and terminally ill people from prejudice, negative and inaccurate stereotypes, and ‘societal indifference’”;

Whereas clearly expressing that assisted suicide is not a legitimate health care service, Congress passed, with a nearly unanimous vote, and President Bill Clinton signed, the Assisted Suicide Funding Restriction Act to prevent the use of Federal funds for any item or service, including advocacy, provided for the purpose of causing, or assisting in causing, the death of any individual such as by assisted suicide, euthanasia, or mercy killing;

Whereas a handful of States have authorized assisted suicide, but over 30 States have rejected over 200 attempts at legalization since 1994;

Whereas States that authorize assisted suicide for terminally ill patients do not require that such patients receive psychological screening or treatment, though studies show that the overwhelming majority of patients contemplating suicide experience depression;

Whereas the laws of such States contain no requirement for a medical attendant to be present at the time the lethal dose is taken, used, ingested, or administered to intervene in the event of medical complications;

Whereas such State laws contain no requirement that a qualified monitor be present to assure that the patient is knowingly and voluntarily taking, using, ingesting, or administering the lethal dose;

Whereas such State laws contain no requirement to secure lethal medication if unwanted or if death occurs before such medication is used;

Whereas such State laws do not prevent family members, heirs, or health care providers from pressuring patients to request assisted suicide;

Whereas such States qualify some patients for assisted suicide by using a broad definition of “terminal disease” and “going to die in six months or less” that includes diseases (such as diabetes or HIV) that, if appropriately treated, would not otherwise result in death within six months;

Whereas it is extremely difficult even for the most experienced doctors to accurately prognosticate a six-month life expectancy as required, making such a prognosis a prediction, not a certainty;

Whereas reporting requirements vary by State, but when required, rely on prescribing physicians or dispensing pharmacists to self-report;

Whereas such reporting is neither conducted by an objective third party nor of sufficient depth and accuracy to effectively monitor the occurrence of assisted suicide;

Whereas there is an astounding lack of transparency in the practice of assisted suicide to the extent that State health departments and other authorities admittedly have no method of knowing if it is being practiced within the bounds of State laws and have no funding or authority to make such a determination;

Whereas some State laws actively conceal assisted suicide by directing the physician to list the cause of death as the underlying condition without reference to death by suicide;

Whereas the confidential nature of end-of-life decisions makes it virtually impossible to effectively monitor a physician’s behavior to prevent abuses, making any number of safeguards insufficient;

Whereas the cost of lethal medication is far less costly than many life-saving treatments, which threatens to restrict treatment options, especially for disadvantaged and vulnerable persons, as has happened in several known cases and presumably many more unknown in which insurers have denied or delayed coverage for life-saving care while offering to cover assisted suicide;

Whereas access to personal assistance services such as in-home hospice and palliative care, home health care aides, and nursing care/nursing assistance is regretfully limited and subject to long waiting lists in many areas, placing systemic pressure on patients in need of such personal assistance services to resort to assisted suicide; and

Whereas for all these reasons, assisted suicide undermines the integrity of the health care system: Now, therefore, be it

Resolved by the House of Representatives (the Senate concurring), That it is the sense of Congress that the Federal Government should ensure that every person facing the end of their life has access to the best quality and comprehensive medical care, including palliative, in-home, or hospice care, tailored to their needs and that the Federal Government should not adopt or endorse policies or practices that support, encourage, or facilitate suicide or assisted suicide, whether by physicians or others.

Woman pressured boyfriend to suicide.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Conrad Roy

Last February, the Massachusetts high court upheld the the voluntary manslaughter conviction of Michelle Carter for assisting the suicide of Conrad Roy who was 18 at the time of his death. Carter, who was 17 at the time of the death, was sentenced to 15 months in prison. The court found that Carter pressured Conrad to die by suicide.
 
Another young woman has been charged after pressuring or assisting her boyfriend to die by suicide.

Alexander Urtula

Inyoung You (21) has been charged with involuntary manslaughter in the suicide death of Alexander Urtula (22) who had an 18 month relationship. Mark Pratt reported for the Associated Press:

Inyoung You, 21, was “physically, verbally and psychologically abusive” to fellow Boston College student Alexander Urtula during an 18-month relationship, Suffolk District Attorney Rachael Rollins said at a news conference.

You sent Urtula, 22, of Cedar Grove, New Jersey, more than 47,000 text messages in the last two months of the relationship, including many urging him to “go kill yourself” or “go die,” Rollins said. You also tracked Urtula and was nearby when he died in Boston on May 20, the day of his Boston College graduation.

“Many of the messages display the power dynamic of the relationship, wherein Ms. You made demands and threats with the understanding that she had complete and total control over Mr. Urtula both mentally and emotionally,” Rollins said.

According to the Associated Press article You is currently in South Korea.

You is in her native South Korea, and it is unclear when she will be arraigned. Prosecutors are in negotiations with You's counsel to get her to return to the U.S. voluntarily, but if she does not, Rollins said, she will start extradition proceedings.

Last July, Massachusetts State Senator Barry Finegold and Representative Natalie Higgins introduced Conrad's Law, a bill to deter suicide coercion. Conrad's law would punish those who coerce others into committing or attempting to commit suicide, with punishment of up to five years in prison. The bill does not apply to assisted suicide, which is illegal in Massachusetts.

Similar to other assisted suicide cases, the person who dies may have been coerced or encouraged to suicide.

Lawyers for Michelle Carter argued that her texts were constitutionally protected free speech and yet the Massachusetts Supreme Judicial Court upheld her conviction. The Carter decision has been appealed to the U.S. Supreme Court, which hasn't yet decided whether it will take up the case.

To reach the National Suicide Prevention Lifeline, call 1-800-273-TALK (8255). You can also text a crisis counselor by messaging 741741.