CHECKLIST FOR USE IN

DRAFTING ASSISTED-DEATH LEGISLATION

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by Ruth von Fuchs

1.

POSSIBLE PROBLEM: Person is not competent to make life-or-death decision (e.g. is pathologically depressed, or is demented).

POSSIBLE SAFEGUARD: Require involvement of psychiatrist or psychologist, in interviewing of applicant or in reviewing of videotape(or audiotape or transcript or ...)

DISCUSSION: (a) Be aware that some sadness and fatigue are normal concomitants of being in a state sufficiently grim that death is desired. (b) Consider allowing intractable depression to be classed with other irremediable conditions which are accepted as valid reasons for desiring death. (c) Recognize directives (and proxy decision-makers) established prior to onset of incompetence, and standardize forms which are sufficiently detailed and clear (enlist help of chronic-care and critical-care specialists, in designing and revising forms).

2.

POSSIBLE PROBLEM: Person is misinformed, and unduly pessimistic, about prospects for future, and/or proposed remedies (e.g. their experiential aspects).

POSSIBLE SAFEGUARDS: (a) Involve additional expert(s) in prognoses and explanations. (b) Involve "peer associations" (e.g. Cancer Society, Bipolar Disorders Society) in counselling of applicant.

DISCUSSION: Misinformation can also be in opposite direction(e.g. doctor may discuss only possible benefits of proposed treatment, or may overstate odds on recovery of health).

3.

POSSIBLE PROBLEM: Person's request for death is impulsive, ill-considered.

POSSIBLE SAFEGUARD: Require "cooling-off" period, or require that request be re-iterated at specified intervals.

DISCUSSION: (a) Length of cooling-off period (or of interval between requests) should be adjustable, within limits, to prevent hardship for people in an acute condition. (b) Waiting time (or interval length)could be inversely proportional to applicant's age (again, within limits) -- e.g. applicants under 30 could be required to think it over for a longer time, and perhaps receive more counselling, than applicants over 30.

4.

POSSIBLE PROBLEM: Person's situation changes dramatically, and assisted-death licence (granted under past circumstances) becomes undesirable "loaded gun".

POSSIBLE SAFEGUARD: Give assisted-death permissions a finite period of validity (e.g. six months).

5.

POSSIBLE PROBLEM: When moment of action arrives, person changes mind(wants to "climb down off diving board").

POSSIBLE SAFEGUARD: Build revocation opportunities into procedure, and allow more than one means of expression (written, oral, "body language"). Have a neutral third party (that is, someone other than the recipient or the administrator of the assisted-death procedure --perhaps a specially-trained social worker) be present to witness the revocation inquiries, or even to be the person who makes them.

DISCUSSION: Problem is less severe with assisted suicide than with euthanasia -- person simply refrains from performing death-causing act. However, social pressure can still operate (need to "save face"), so should be offset or neutralized by tone and context of revocation inquiries.

6.

POSSIBLE PROBLEM: Remedy for person's condition might be on the way, and suicide or euthanasia would mean person could not benefit from it.

POSSIBLE SAFEGUARDS: (a) Limit aid in dying to cases where X experts judge that applicant has less than Y months to live; (b) Limit aid in dying to cases where X experts judge that probability of remedy being found within Y months is below Z%; (c) Limit aid in dying to persons who state that even if remedy were found within Y months, they would not want to endure the experiences that would come to them in the intervening period.

DISCUSSION: Regarding safeguard (a), above: effect of this policy could be to make availability of aid inversely proportional to need for aid (if you are likely to suffer for only 4 weeks more, you can obtain release; if you are likely to suffer for 4 years more, you cannot).

7.

POSSIBLE PROBLEM: Person's heirs (or potential vendors of person's organs) could apply pressure, making person ask for death before person truly wants it.

POSSIBLE SAFEGUARD: Exclude beneficiaries from involvement in assisted-death procedure (e.g. forbid them to witness a request, or be a proxy decision-maker).

DISCUSSION: In many cases, the people someone loves enough to bequeath them money are also the only people whom that person trusts enough to name them as health-care proxies. Disinterested (but interest-paying) third party -- e.g. "Public Guardian" -- might need to have role, as temporary custodian of bequest during clearance procedures (review of videotaped interviews, etc.).

8.

POSSIBLE PROBLEM: If doctor works in fee-for-service mode, will have incentive to push patient towards doctor-administered euthanasia.

POSSIBLE SAFEGUARD: Confine administration of euthanasia to doctors who are retired, who work on salary, or who for some other reason do not benefit financially from performing procedure.

DISCUSSION: Financial incentives for doctors to work against patients' interests exist under present laws. As long as surgery (or other paid-to-doctors procedures) can be plausibly prescribed, patients who would benefit more from death may be kept alive to generate income for others.

9.

POSSIBLE PROBLEM: Person might leave before really wanting to, out of guilt at being a burden (e.g. making children spend savings, stall careers) or at not being a "productive" member of society.

POSSIBLE SAFEGUARDS: (a) Start or extend government-financed care programs, and pay workers well enough to attract people able to give care as good as that given by loving relatives; (b) Maximize and rationalize care programs that use volunteers; (c) Redefine"productivity" to include more than having a paid job.

DISCUSSION: Recognize that some people may have -- as part of their individual value system -- a repugnance to helplessness, or to what they experience as selfishness. To force them to live in contradiction to their intrinsic values is to violate them at a very personal level.

10.

POSSIBLE PROBLEM: Person's family could be shocked or hurt if not involved in (or at least notified of) person's assisted-death request.

POSSIBLE SAFEGUARD: During waiting period, attempt to notify (and involve, without veto powers) applicant's closest X relatives.

11.

POSSIBLE PROBLEM: Trends develop that reveal factors needing attention (e.g. inadequate variety or currency of treatments for depression, in a certain locality).

POSSIBLE SAFEGUARD: Require notification of coroner's office, each time an assisted-death permission is acted upon; and require coroner's office to compile and publish statistical reports.