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How California could dramatically change assisted suicide debate

California recently legalized doctor-assisted suicide. As the largest state in the nation, it could present challenges other states have not experienced.

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    Dan Diaz holds a photo of his late wife, Brittany Maynard, during a rally calling for California Gov. Jerry Brown to sign right-to-die legislation at the Capitol in Sacramento, Calif., last month. Governor Brown signed the bill earlier this month.
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With California legalizing physician-assisted suicide this month – and several other states considering the move – the practice is about to get a lot more scrutiny. 

Evidence suggests that, so far in states that have adopted assisted suicide, those who have ended their lives are have tended “to be white, well-insured, well-educated, and well cared for,” says James Hoefler, a political scientist at Dickinson College in St. Carlisle, Pa., who studies right-to-die laws.

But in California, assisted suicide is entering new territory. The demographics, economics, and health care structure in California are different than they are in Oregon, Washington State, and Vermont, where assisted suicide is already legal.

That will put the system under new pressures – particularly the persistent concern that economic calculations could tempt families or insurers to push patients diagnosed with a terminal illness to end their lives.

“You cannot deny the numbers,” says Jeff Helton, professor of health care management at Metropolitan State University in Denver, who supports assisted suicide, and who spent most of his career consulting hospitals facing bankruptcy. “Certainly the prescription for an assisted suicide fill, depending on the cocktail that is prescribed – you’re talking about $40 to $50 versus what could be years of palliative care.”

The pressure of health care costs

The issue is a pressing one in California and nationwide. Health care costs make up more than 17 percent of nation’s gross domestic product – nearly double the average of other industrialized countries – and they are rising.

And as in other states, hospice and palliative care can be spotty in some parts of California. In general, the United States does poorly with this part of the health care infrastructure, experts say. And if the poor covered by state Medicaid do not have access to such care, there is a concern among medical ethicists that they could be forced toward assisted suicide.

“I’ve personally seen those types of situations where the family is feeling, How are we going to take care of this terminally ill relative?” says Professor Helton of Metropolitan State. “And it creates a lot of very difficult family dynamics, and difficult dynamics with the patient's care giver, to be sure.”

California’s law does not require private insurance companies to cover the costs of assisted suicide, and officials are still considering whether the state’s Medi-Cal program for the poor will cover the costs of the drugs and treatments. Oregon’s state medicaid program does cover such costs, though Washington and Vermont do not.

The tightly-regulated process of assisted suicide costs about $1,500 per patient, according to reports, compared with the average cost of nearly $33,500 per patient in the US in the final year of life. 

New momentum, new challenges?

For now, there is scant evidence, if any, that such financial incentives play any role in the systems of Oregon, Washington, or Vermont, say Professor Helton and others. The numbers of people choosing to take their lives has been relatively small, and they have been relatively well-off.

Since Oregon pioneered assisted suicide policies in 1997, doctors there have prescribed 1,327 prescriptions for lethal doses of drugs, which terminal patients must be able to administer themselves, though only 859 have taken their lives. Some 93 percent of those asking for assisted suicide in Oregon last year were enrolled in hospice.

But California, with its diverse population and complex health care system, could present a much different environment, observers say. And California’s national profile could launch new momentum for the death-with-dignity movement.

This year, 17 state legislatures and the District of Columbia have considered new physician-assisted suicide bills for the first time, with eight others considering the policy in years past. Polls show support for physician-assisted suicide has jumped.

“California is the first really big state, so we’ll get to watch how this unfolds now, and it might be a game changer,” says Dena Davis, chair of the health department and professor of bioethics at Lehigh University in Bethlehem, Pa. “You’re going to have a very large state with enormous diversity, a very religiously, ethnically, and economically diverse bunch of people, and it will be interesting to see what happens.” 

Opponents – and even some advocates – worry about how these policies will evolve into the future. Current laws limit the assisted suicide option to terminal patients diagnosed with six months to live, usually after expensive treatments have been exhausted. But a “slippery slope” argument suggests that as the situation evolves over years or decades, people might begin to clamor for assisted suicide for Alzheimer's, Parkinson's, and onset dementia.

A web of difficult decisions

Oregon’s law, which became the basic template for Washington state’s 2008 law, Vermont’s 2013 statute, and now California’s, has multiple check and balances to prevent this. It requires the patient to make two oral requests to their doctor, at least 15 days apart. The patient must also then put the request in writing.

Doctors must then judge the mental competency of the patient, and inform him or her of all feasible alternatives, including hospice and palliative care. And then patients must administer the lethal drugs themselves.

Still, many look at a case from eight years ago with concern. An Oregon doctor prescribed an expensive cancer drug to Barbara Wagner, a low-income resident who was diagnosed with terminal cancer, in an effort to extend her life a few months. But Oregon’s state-sponsored health plan refused to cover the high costs of the drug, since it did not meet a required, low-bar threshold: a survival rate of at least 5 percent over five years.

In the letter explaining the denial of coverage, the state listed a number of other options that would be covered in full, including assisted suicide.

"It was horrible," Wagner told ABCNews.com in 2008. "I got a letter in the mail that basically said if you want to take the pills, we will help you get that from the doctor and we will stand there and watch you die. But we won't give you the medication to live."

She did eventually get the drug after the case prompted the company to give it to her for free. Wagner died soon after.

Few deny that health care systems must make such judgements, and drugs must prove that they are minimally effective, most experts say. Nevertheless, the case illustrates the fraught nature of the decisions insurers and government programs must make.

For its part, Oregon has since stopped listing assisted suicide as an alternative when denying patients other treatments.  

 “I understand that from a PR perspective, listing that was probably a really bad move,” says Professor Davis of Lehigh. “On the other hand, from an ethics perspective, I would be frustrated if that option were not out there, clearly on the table.”

The call for better care

The bigger issue in California could be the sheer size of the state and the gaps in its health care system, some say.

“The real question is, in a large state like California, with a lot of folks with lousy access to care, are they going to have the option for palliative and hospice care?” says Arthur Caplan, professor and founding director of the division of medical ethics at New York University’s Langone Medical Center. “You don’t want them picking [assisted suicide] because they think, ‘Hmm, I’m not going to get pain relief, and I can’t get my way into a hospice, so now it’s time for me to go.’”

In this way, assisted suicide creates an imperative for improving those areas of health care, adds Dr. Caplan, who supports assisted suicide. 

“So are you going to expand palliative care and hospice for people who can’t get it?” he says. “I’d be very worried if that didn’t happen…. As I’ve said to proponents of physician-assisted suicide, you should be the greatest proponents of hospice, if you want to see this done properly.”

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