Special supplement: Euthanasia

...The failure of the California initiative, which directly called for exemption from the homicide statutes, was instructive...

...This article began with the dire prediction of a moral cataclysm...

...Citizens can circulate a petition for signatures and, if enough are obtained, place their proposition on the ballot at a general election...

...The state has a heritage of progressive, even radical, politics...

...Some persons, particularly its proponents, would see this not as a moral cataclysm, but as moral enlightenment...

...Whether opposition can effect a change in public understanding and sympathy between now and November remains to be seen...

...Initiative 119 was circulated with the official ballot title, "Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in-dying...

...Ironically, neither case would fit under the provisions of the amended act, since Ms...

...s of this writing, opposition efforts have been modest...

...It makes this radical change seem less radical by incorporating it into accepted legislation...

...Thus, Hemlock's message would be received with tolerance in such a political and moral climate...

...Still, a recent poll showed that if the vote were held today, 119 would pass...

...Still, the exposure in the media must have stimulated interest and spurred the signature campaign...

...A legislative system such as this is ideal for the debate and resolution of broad issues of public concern, although it can place severe restraints on policymakers on such issues as taxation and education...

...Several Supreme Court decisions in the early 1980s endorsed the concepts of total brain death, of forgoing life support of the patient in a persistent vegetative state, and of the right to refuse life-sustaining care...

...Specify which life-sustaining procedures may be withdrawn...

...The legislature decided not to consider the initiative...

...If our citizens approve Initiative 119, we will make our state the first American jurisdiction, indeed, the first jurisdiction in the world, to legalize active euthanasia...

...These safeguards are, however, only relatively conservative...

...Permit adult persons with terminal conditions to request and receive aid-in-dying from their physicians, facilitating death...

...This climate might be a favorable one in which to introduce the next question: Should the law tolerate active euthanasia...

...The final provision, permitting "aid-in-dying," is the radical departure from prevailing law and medical ethics...

...While it is odd to find this mention of an active, voluntary request in a document otherwise devoted to advance directives to be carried out on behalf of incompetent patients, the idea of amending the extant Natural Death Act was politically and psychologically astute...

...There will be a flood of persons seeking aid-in-dying, coming from all over the United States and Canada, since only in Washington will their desire to end their lives be honored without fear of prosecution...

...In April, the WSMA board of trustees, without rescinding the earlier House of Delegates vote, decided not to recognize officially the private group, Washington Physicians Against 119, which was formed to mount a campaign against passage of the initiative...

...The considerations, private and public, that must surround it will constitute a social order that, as the dictionary defmes cataclysm, sweeps away the old order of things...

...On November 5, 1991, the citizens of this state will vote on Initiative 119...

...The benign phrase, "aid-in-dying," like the deceptively beautiful slopes of Mt...

...The evidence of public acceptance is not out of line with the results of recent national opinion polls that show slight majorities in favor, when asked clear questions about the permissibility of active euthanasia...

...Fortuitously, two cases that received media exposure occurred during the signature gathering: the U.S...

...The Pacific Plate could slip beneath our lovely landscape and busy cities and tear our state to pieces...

...Given the size of California's electorate, paid signature-gatherers are necessary and Hemlock did not have the funds to organize such an extensive activity...

...It amends current law to: Expand the definition of terminal condition to include irreversible coma and persistent vegetative state or condition which will result in death within six months...

...California passed the first Natural Death Act in 1976...

...This is not, I think, an unambiguous opportunity: its implications go far beyond the beneficent promotion of autonomy and the relief of pain and suffering...

...This legislation, following the California model, has been criticized for its overly cautious definition of "terminal condition" and for its omission of explicit reference to nutrition and hydration as life-sustaining measures that may be forgone...

...The group began to gather signatures on an initiative that would exempt from prosecution ttnder the homicide statutes any physician who caused the death of a patient voluntarily requesting such assistance...

...In the midst of this beauty lies peril...

...This service consists in the administration or provision of a lethal drag to effect the immediate death of the patient...

...Yet to become the first jurisdiction in the world to authorize by formal legal enactment active euthanasia has, in my view, cataclysmic implications...

...These innocuous, indeed benign words, refer to what its proponents describe as "a new medical service...

...Respect for autonomy and privacy is a cherished social value in the Great Northwest...

...The state of Washington has a history of reasonable public policy about death and dying...

...Third-party payers will have to decide whether aid-indying is a covered and reimbursable medical service...

...Hemlock officials believe that the failure to obtain sufficient signatures was due not so much to opposition to their proposal as to the large number of signatures needed...

...This ballot provision would allow a competent, terminally-ill patient to request of his or her physician "aid-in-dying...

...Wide expanses of water, towering forests, broad plains, and splendid mountains surround its 5 million inhabitants in the northwest comer of the "lower forty-eight," as our Alaska neighbors say...

...The legislature subsequently passed a Durable Power of Attorney for Health Care law and amended the state statutes to include a list of authorized surrogate decision makers for incompetent patients...

...It had previously endorsed the AMA Ethics and Judicial Council statement that forbids physicians to participate in active euthanasia...

...Also, religious opposition, which could be expected to be strong, would not be as powerful in Washington as elsewhere...

...At the annual meeting in 1990, the WSMA House of Delegates voted by an overwhelming majority to oppose Initiative 119...

...In the 1930s, one of Roosevelt's cabinet officers raised a toast to "the forty-seven states and the Soviet of Washington...

...Its Natural Death Act permits persons to prepare an advance directive authorizing their physician to withhold or withdraw life-sustaining procedures when death is imminent...

...It appears to many observers that the public continues to confuse the problem of forgoing life-support with the problem of active euthanasia...

...However, there is no mention of presence or evaluation of pain and suffering, no reference to stability of the patient's request over time, no requirement for psychological 467: Commonweal Supplement: 3 evaluation (safeguards that are mentioned in reports of the Dutch tolerance of active euthanasia...

...An informal poll of 2,000 members (50 percent responding) indicated a shift in attitude: 49 percent favored WSMA support of Initiative 119, while 51 percent opposed it...

...The same poll, however, showed that only 28 percent of respondents thought that it should be legal for a physician to give a lethal injection to knowingly hasten death and 30 percent stated that they would personally be willing to aid in a patient's death...

...Washington was the second state to do so, enacting a bill substantially similar to California's in 1979...

...Reaction within the medical community has been hard to interpret...

...Hospitals will have to decide not only what stance they will take, but how to inform patients of their position (in accord with the new patient self-determination provisions of Medicare) and even how the new law will affect their admissions and credentialing policies...

...However, by March 1991, WSMA members seemed nearly evenly split over the issue...

...The state, then, has a legal climate open to liberal opinions about issues of death and dying...

...Its judicial and legislative policies reflect the wide agreement among bioethics scholars and national advisory groups on most issues...

...The state of Washington is also on the edge of a moral cataclysm...

...Legal authorities, since they seem to have no jurisdictio n , will have to determine how they deal with suspicious case s and allegations of abuse...

...The ambiguity of the phrase "aid-in-dying" contributes to that confusion...

...The public response to the initiative was quite positive...

...The Hemlock Society has been seeking an opportunity to put this question before the public...

...The Washington State Hospital Association takes an opposed position and, while it will not actively campaign, will assist its member institutions to do so...

...Helens, erupted ten years ago, devastating the landscape and, only a few weeks ago, geologists announced that our risk of major earthquake was much greater than had previously been assumed...

...A recent survey showed Washington as one of the most unchurched states in the nation: at 14 percent, it is surpassed only by its neighbor Oregon (17 percent) in the number of persons who claim no religious affiliation (the national average is 8 percent...

...Only on the issue of withdrawal of nutrition and hydration has Washington's Supreme Court maintained a conservative position, at least for mentally incapacitated persons...

...Perhaps most significant, the attitude of Washington inhabitants is strongly live-and-let-live (or, in this case, let die...

...Above all--and this is the properly "moral" aspect of the cataclysm--all persons will be presented with the opportunity to relieve themselves and their families and the society of the burdens of their own final illnesses...

...he Natural Death Act would be amended to define "aid-in-dying" as "aid in the form of a medical service, provided in person by a physician, that will end the life of a conscious and mentally competent qualified patient in a dignified, painless, and humane manner, when requested voluntarily by the patient through a written directive...at the time the medical service is to be provided...

...Supreme Court's decision in the matter of Nancy Cruzan, which stimulated interest in advance directives, and the "mercy killing" of Janet Adkins by means of Dr...

...The Hemlock Society chose to bring the issue of the legality of active euthanasia before the people of California in 1988...

...Most media coverage has tended to present the initiative in a favorable light, since the appealing stories relate tragic instances of terminal care...

...Next, an attempt to mount an initiative 2: Supplement Commonweal: 466 in Oregon failed to qualify for signature gathering because of a successful challenge to the ballot title...

...In many ways it was more ideal than California...

...I will explain what Initiative 119 is and how Washington came to be the site for this historic public decision...

...The WSMA spokesperson stated that since the membership was divided, "there were other ways to oppose it without getting directly involved...

...Washington Citizens for Death with Dignity, supported by the Hemlock Society, was able to gather 223,000 signatures...

...4: Supplement Commonweal: 468...

...It fits the radical provision within the relatively conservative safeguards of the extant act...

...An informal and unpublished survey taken by some opponents suggests that public approval of Initiative 119 diminishes somewhat when people are informed of the difference and when terms such as lethal injection are used rather than aid-in-dying...

...Astute politicians judged that a ballot measure would split the vote in such a way that Initiative 119 would be assured of victory...

...Adkins was not suffering from a "terminal condition...

...This may seem an extreme judgment...

...Physicians will have to form their consciences and, if they choose to provide aid-in-dying, learn how to do it (as a new "medical service" it will, like all others, require standards and training: it is not so easy to effect a "dignified and humane" death...

...The Washington State Medical Association (WSMA) found itself in a quandary...

...Proposition 119 buries this feature in the text, mingling it with the previous exemption from criminal liability for physicians who forgo life sustaining treatments in accord with a Directive to Physicians (a very different issue, legally and ethically...

...Its population is much smaller and thus only 150,000 signatures were needed...

...Jack Kervorkian's "suicide machine...

...One of its peaks, Mt...

...Because only 137,000 of the requisite 378,000 signatures had been obtained by the deadline, the initiative failed to reach the ballot...

...The Washington State Nurses Association at first opposed the initiative and then, after intense lobbying, withdrew its statement of opposition in favor of "no position...

...Washington's initiative and referendum law allows an approved initiative to go before the state legislature for action...

...119 and to any policy permitting active euthanasia...

...The official summary of the initiative read: This initiative expands the fight of adult persons with terminal conditions to have their wishes, expressed in a written directive, regarding life respected...

...This aspect of the initiative has generally been welcomed (although defining persistent vegetative state as a "terminal condition" seems a semantic sleight of hand...

...Like most Natural Death legislation, they require witnesses unrelated by family or financial interest and the written declaration by two physicians that the patient is in a terminal condition, that is, the reasonable medical judgment that death will result within six months...

...The term literally means a deluge...

...If the legislature fails to enact the initiative, it is to go on the ballot at the next general election...

...The patient must simply be diagnosed as being in a terminal condition and make an uncoerced request for aid-in-dying...

...However, I rely on others in this issue to put forth extended arguments against the proposition...

...Helens, conceals the potential for cataclysm...

...That decision, In the Matter of Grant, is a legal chimera: the majority opinion presents an eloquent argument justifying withdrawal, while the majority vote rejects withdrawal, a judicial oddity resulting from one justice who changed her vote on reconsideration after the opinion was published...

...I am opposed to Initiative ALBERT R. JONSEN is professor and chairman of the Department of Medical History and Ethics at the University of Washington...

...Cruzan was incapable of making a voluntary request and Mrs...

...The initiative amends the act to correct these deficiencies...

...Obviously, I take a different view...

...Washington was the next target of opportunity...

...The current law which these provisions will expand is the 1979 Natural Death Act...

...California, Oregon, and Washington are among the few states that have an initiative and referendum process...

...This process is the heritage of the strong populism that reigned in the Western states at the turn of the century...

...It associates it with useful and broadly approved amendments...

...In addition to the progressive legislation and judicial climate about death, Washington has a liberal ethos...

...The directive is to be witnessed by two unrelated and impartial persons and the patient must be declared "in a terminal condition" by two physicians...

...Washington's dates back to 1911...

...Professional groups will be faced with the task of establishing appropriate self-discipline and surveillance, since, like other medical services, aid-in-dying falls within professional self-regulation...

...At last, they say, a government has listened to the voices of those philosophers who construct rational arguments justifying euthanasia and to the pleas of suffering patients requesting a humane and dignified death...

...Most of the anecdotes tell of overuse of life-sustaining technologies rather than of unrelieved pain and suffering...

...Most important (and most different from the Dutch practice), Initiative 119 appears to remove the aid-in-dying decision and execution from all legal oversight...

...The society had its first chapter in Southern California and had developed an organizational base in the state...