Medical Aid in Dying: Bioethical and Public-Policy Perspectives

Medical Aid in Dying: Bioethical and Public-Policy Perspectives

In our American world of advancing technology and individual self-determination, we have, in many ways, unprecedented choice over how we want to live. But should we be able to choose how we die?

Assisted suicide (or medical aid in dying, as some advocates more inclusively refer to it) is a complex and emotional issue that must be viewed from the many social, political and ethical layers in which such a decision is couched.  The first part of this series featured a Jewish theological perspective from Rabbi Elliot Dorff; he is followed here by his co-panelists, bioethicist Dr. Don Postema and Minnesota Representative Mike Freiberg.

(This post is part of Sinai and Synapses’ project Scientists in Synagogues, a grass-roots program to offer Jews opportunities to explore the most interesting and pressing questions surrounding Judaism and science. “Medical Aid in Dying [M.A.I.D]” was a panel and moderated discussion held at Beth Jacob Congregation in Mendota Heights, MN on May 5, 2024.)

Dr. Don Postema is currently Program Director of Medical Bioethics for HealthPartners, working with the hospitals and caregivers within the organization and chairing the HealthPartners Ethics Committee.  His responsibilities include providing ethics consults, ethics education, and policy review.  His graduate work in philosophy was at Columbia University, and he has been a Visiting Scholar at the Hastings Center, the University of Washington, the Minnesota Center for Health Care Ethics, and the University of Minnesota. In his parallel career in academia, Dr. Postema taught philosophy, ethics, bioethics, philosophy of art, and film studies at Bethel University where he is an Emeritus Professor of Philosophy. He is an Affiliate Faculty member at the Center for Bioethics at the University of Minnesota.

 

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Minnesota State Representative Mike Freiberg is currently serving his sixth term in the legislature representing the cities of Crystal, Golden Valley, Plymouth and Robinsdale. Representative Freiberg is also an attorney working on health policy issues when he is not legislating at the Capitol. Representative Freiberg is a strong advocate for many issues affecting children in the state, on issues such as vaccinations and preventing gun violence, and in 2019 was the recipient of the Minnesota chapter of the American Academy of Pediatrics’ Annual Advocacy Award. Representative Freiberg is the author of the Minnesota End-of-Life Option Act (SF1813/HF1930).

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Mike Freiberg: I just sort of, through the course of the speakers here, I took some notes on my phone, so if you see me looking at my phone I’m not, like, checking the Twins score to see if they’re continuing their winning streak, but just want to make sure I mention what I want to mention here.

So yeah, I’m the author of the end-of-life option act, which authorizes the process of medical aid in dying. I’m glad both Rabbi Dorff and Dr. Postema sort of acknowledged the distinction in terminology here between terms like “assisted suicide” and “medical aid in dying.” I definitely prefer the term “medical aid in dying.” And actually they both did a great job of kind of covering this issue, so hopefully there are still some things left for me to say. That’s always the risk in going last, particularly when you’re preceded by such distinguished speakers. 

So Dr. Postema showed, sort of, the brief description from our research department on the summary of the bill, but I’ll just go over it quickly because there was a fair amount of text up there. So the bill follows the practice in the 10 states that have authorized medical aid in dying. It says that if you are diagnosed by a medical provider with having a terminal illness, which means that you have six months or less to live, and it’s verified by a second health care provider and you are of sound mind – so, you have ability to make an informed decision – then the medical provider can prescribe for you a medication which you have to be able to self-administer that will end your own life. So this is not something – nobody can give you an injection or an infusion or anything like that. You have to be able to self-administer it. 

And I mentioned that the person has to have mental capacity. Rabbi Dorff mentioned the case of clinical depression – you know, that could impair a person’s ability to make an informed decision. So could something like Alzheimer’s disease. I’ve actually had requests from many people to expand what the bill would authorize, too, because they say, quite understandably, that “If I ever have Alzheimer’s disease and I’m advanced to a point where I don’t know who I am, I don’t know who my kids are, I should be able to end my own life.” But a critical component of the bill is that the person has the ability to make an informed decision, and they wouldn’t in that case. So we have not expanded it  to that point. 

Rabbi Dorff mentioned the problem of money. I think it’s important to mention that the bill criminalizes coercion, so nobody can coerce a parent to make this decision because they’re concerned about the financial impact of continued medical care. So any form of coercion is a penalty. We talked about that in one of the Committees. 

Differences Across States

And the requirements are the same, as I mentioned, as in the 10 states that have authorized medical aid in dying. So it’s similar to the California law that Rabbi Dorff described. It’s been expanded by a Supreme Court decision in Canada, but that does not apply in the United States, so it’s not been expanded to people with Alzheimer’s or anything like that in none of the 10 states. The basic requirements that I outlined, have always stayed the same. And I think that’s kind of a counterargument to the slippery-slope argument that Rabbi Dorff mentioned. Certainly, you want to consider that in any law you’re advocating for, but I think when you have a record of 20 years where the basic requirements haven’t changed in any US state, I think that kind of is a counterargument to the slippery-slope argument. 

Just some statistics here – most of the people, about 90% of the people who’ve utilized medical aid in dying in the states that authorize it, have certain forms of cancer or ALS. They are in hospice, for the most part, in the states that authorize it. They’re already there. Medical aid in dying is completely compatible with hospice and palliative care. And I completely agree with Rabbi Dorff about the goal that it’s important to visit people who are suffering from terminal illnesses. And I think it’s not only compatible with MAID, but the experience from other states that have authorized it shows that it can kind of bring people together. In the legislative hearings we’ve had, there has been very compelling testimony, very emotional testimony, from people who’ve seen their loved ones, who’ve helped their loved ones, go through this process, and just they had a beautiful experience, where the person’s suffering ended. Their family was all present, and I think hopefully it can counteract some of the loneliness that Rabbi Dorff talked about.

So just in terms of where the bill is at this year, it’s gone further than it’s ever gone before. We’ve had what we call “informational hearings” in previous sessions, where no action, no official action, is actually taken on the bill. But this year, there have been hearings in four committees in the Minnesota House. It started with a five-hour-long hearing in the Health Committee before the session started, and then it’s been heard in the Public Safety Committee, the Judiciary Committee, and the Commerce Committee, because of some of the insurance provisions that are in there.

Can We Pass the Bill This Year?

So the goal, in my mind, kind of advances – you know, this year, we have sort of a Democratic trifecta. We’ve passed legislation, I think, that emphasizes bodily autonomy. I was glad to hear from Dr. Postema that autonomy is not just a legislative goal but an ethical goal as well. So we’ve passed legislation like the Protect Reproductive Options Act, which puts the ability to access reproductive care, including abortion care, into the Minnesota statutes. We’re hoping to put it into the Minnesota Constitution as well. 

And I think the End-of-Life Option Act is an important piece of legislation that also authorizes bodily autonomy, this time at the end of life, which I think is a critically important time in our life as well. 

So I said, we’ve made greater progress than we ever have on this bill. I’ve been carrying it for eight or nine years at this point, reintroduced it every year. Prior to this session, we [always] had divided government of some form. It’s generally been opposed by the Republican party. At this point – so I should say, let me clarify that if you do a poll of Minnesotans or American citizens, people of both parties tend to support this, but unfortunately, working in a legislative setting, legislators can be very influenced by the opposition of organized and financed groups. So in my mind, the elected Republican legislators don’t necessarily reflect the view of of a majority of Minnesotans, even Republican Minnesotans, because I think almost everyone has seen somebody, knows of somebody, who’s died, and many know somebody who’s gone through a lot of suffering at the end and would have liked to have this sort of option. So it’s been opposed by the elected Republicans at this point, and there is very organized opposition, as well, from groups that are largely lined up on the same lines as the abortion debate. So the Catholic Church has funded a group that’s calling themselves the association for ethical health care, I think, and they turn out people to testify against the bill.

Opposition to the Bill

There’s a lot of misinformation about the bill, too, that’s out there, that’s kind of encouraged by the groups and people who oppose the bill. So we hear testimony in the Committees that this is going to be used to target people with disabilities. And Dr. Postema mentioned how this could affect our views of disability. But having a disability does not qualify somebody to use medical aid in dying. Certainly, it’s possible somebody might have a disability and also a terminal illness, in which case they might qualify, but if they just have a disability, you know they’re leading, hopefully of a good, productive life and they don’t have a terminal illness, so they are not eligible to use medical aid in dying. And the experience from the other states shows that the people who use medical aid in dying are mostly well-educated, fairly well-off, and haven’t had a disability in the past. As I said, it’s generally people with cancer and ALS. 

So that’s kind of the organized opposition. I mentioned that the Bill’s gone further than ever before. We’ve had four legislative hearings in the House. Unfortunately, it’s been a little more difficult to make progress in the Senate, and it – I mean, I’m not going to say the bill is over at this point, we still have a few weeks left in the session, and a lot of things can change, but there have been a couple Democratic – two, in fact – Democratic senators who’ve made some public statements against the bill, and the Democrats have a one-seat majority in the Minnesota Senate, so it’s always had kind of a tough – it’s certainly had a tougher hill to climb in the Senate than in the House. 

As I said, things can change. I know there have been efforts to reach out to those senators, and there’s a possibility that a Republican senator could support the bill too. So I certainly haven’t given up hope for this session, even though there’s not that much time left, but it’s something. If it doesn’t happen this year, I plan to continue to advocate for it, because I think it’s an important bill that lines up with the goals of the current legislative majority, as well as with myself personally. If I’m ever in that position of having a terminal illness, it’s an option I would like to have. My parents, who are in their 80s, have said to me they want to have this option, and they want this bill to pass. So I just think it’s really important, and I’m encouraged by the response I’ve seen from different communities. I know the Jewish community is one we’ve been trying to reach out to for a long time, so it’s great to be here at Beth Jacob, and I appreciate your interest in the bill and, you know, am happy to answer any questions anyone has.

Sheldon Berkowitz: Thank you, Representative Freiberg, for explaining your bill to us. Let’s give all three of our wonderful speakers a round of applause.

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