4 of 5 in series by Sarah Moon

For the past few years, the Minnesota House of Representatives has attempted to introduce the End-of-Life Option Act HF 1358 and SF 1352 which proposes an option for physician-assisted suicide or, as the bill refers to it, Medical Aid in Dying (MAID). Year after year, the bill has been sidelined for numerous reasons, but mainly for the lack of bipartisan support. This is a heavily Democratic party bill for the state. However, support has steadily increased each year. I wonder how support will look for the 2022 legislative session with the sobering reality of a pandemic that left many severely ill and hospitalized with long lasting symptoms and pain.

In this series, Euthanasia in America, readers have had the chance to think about their stance and what they believe to be true of dignity, freedom, and suffering. (If you haven’t read those articles, I strongly encourage you to start at the beginning before diving into the bill itself).

Now it is time to put those foundational beliefs into action. To start, I pose three questions for the reader:

1. What is human dignity and where does it come from?
2. While dying, how should freedom be offered to and expressed by patients?
3. What role does suffering play in the world if any?

These are all things to keep in mind when making a prudential judgment about Minnesota’s End-of-Life bill.  With these in mind, let us look at some specifics of the bill which I will offer my own analysis of as a public health professional.

Bill Overview

Before I provide my own analysis of the bill, it seems reasonable to introduce the bill with some of its core concepts and key changes to Minnesota’s bill which are absent in the ten other states with MAID acts. At the core of this bill is the desire to give control and autonomy to terminally ill patients while making medical decisions and to alleviate some level of suffering.

There is a long section at the beginning of the bill with a few key terms that are defined by the authors in which I find important to highlight. The first is who qualifies for MAID. It is proposed that anyone over 18 years of age who has not been coerced, has a prognosis of six months or less to live, and is deemed mentally capable can request life-ending medication. People must understand who the population is that will be directly affected by this bill. The second distinction I want to highlight is the term informed decision. “Informed decision means a decision by a qualified individual to request and obtain a prescription for medication pursuant to this section that the qualified individual may self-administer to bring about a peaceful death, after being fully informed by the attending provider and consulting provider of… [their state of health and various options].”[1] My eye was drawn to the word peaceful. Upon further reading, there was no clarification as to what a peaceful death or peace meant in this context.

The Good

Starting off with what I appreciated about the proposed law is a good exercise in humility. In Subdivision 5 Paragraph C, all MAID requests must be submitted in writing by the requesting individual and an advanced health care directive will not suffice. This will help ensure that this is the patient’s wish. In that same section, it states that, “the consulting health care provider shall offer the individual an opportunity to rescind the request.” This gives patients a clear out to their decision to accept life-ending medication.

On the provider side, there is a safeguard for physicians who do not wish to participate in MAID. In Subdivision 11 Paragraph C, a provider has a choice in participation, and if he or she declines, they may transfer the patient to another provider. Informed consent and conscientious objection are essential to any medical policy, but they aren’t the highest of virtues when making medical decisions.

The Bad

There are many areas of this bill that are vague and contradictory to current laws in Minnesota and since hearings haven’t started for the 2022 session, I don’t know how lawmakers would answer my (and many others’) objections. First off, the way the author defines terminal disease gives me pause. It is stated that a terminal disease means “an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months”.  The words incurable and irreversible leave no room for human error. The language is so definite and ignores the fact that “medical mysteries” or miracles do happen.

A few things in Minnesota’s bill are different than the previous MAID bills in other states. The bill’s main author, Representative Mike Freiberg, spoke to the University of Minnesota Center for Bioethics this past January about some of these changes.[2] He noted that he intentionally included a wider net of providers who could authorize life-ending medications. Nurse practitioners are included in this new bill but have not been in the past. The other changes he made were that no witness signature was needed to confirm that the patient orally requested medical aid in dying and that there was no waiting period between the requests of a terminally ill patient. In other states, patients must wait up to 14 days to make their second request. In Minnesota, however, that waiting period has been diminished because it can be seen as a barrier to this option.

Finally, Section 7 has to do with death certificates. These six paragraphs are the most revealing about the whole issue. In these paragraphs, it is stated that death certificates will not include that life-ending medication was administered, that the cause of death will be listed as the underlying terminal disease, and that the death will not be designated as a suicide or homicide. What is revealed in this language almost seems like shame. If this is an acceptable and honored way of dying, why wouldn’t it be ok to mention it on one’s death certificate? To make no mention of MAID on a death certificate is both inaccurate and misleading. Inaccurate because the primary cause of death were the life-ending medications. The underlying condition could be a secondary cause of death that attributed to one’s decision to end their life, but I don’t believe it should be considered the primary cause of death. This choice by the authors can also lead to misleading statistics. For example, when researchers look at cancer mortality rates, they may analyze death certificates and the primary cause of death. There would be an overstated amount of cancer deaths in a state with MAID laws because the coroner cannot accurately code the cause of death. If MAID is a good thing for Minnesotans, I believe that the state, physicians, and patients shouldn’t be afraid to admit it on death certificates.

The Confusing

Lastly, the confusing parts of this proposed bill. There are many parts that use broad, vague language when referring to what it means to be mentally capable or, terminally ill.  So too, even the conscientious objection section needs some work on bulking up protections for those providers who refuse to participate.

My main concern is found in Section 3 Paragraph 1 in which the authors write, “no person or health care facility shall be subject to civil or criminal liability or professional disciplinary action, including censure, suspension, loss of license, loss of privileges, loss of membership, or any other penalty for engaging in good faith compliance with sections 145.871 and 145.872.” Essentially this is saying there’s no penalty to providing information about killing oneself and/or knowingly prescribing lethal drugs. This is contradictory to Minnesota’s homicide statutes though. In Section 609.215 of MN Statutes, it is written that, “whoever intentionally advises, encourages, or assists another in taking the other’s own life may be sentenced to imprisonment for not more than 15 years or to payment of a fine of not more than $30,000, or both.”[3] The only exceptions to law are found below and there are two about health care providers. The first exception is about administering drugs to alleviate pain and the unintended consequence is death. This would not include the administering of drugs designed to kill someone. This is all confusing because it seems to be that before HF 1358 can be enacted, the Minnesota homicide statutes would need to be modified as well.

Next Steps

There is much to digest in this proposed law. Ultimately, I believe, at its core, it is a poorly written and immoral law. If you come to a similar conclusion, there are ways to stay connected and to get involved. I recommend following the MN Alliance for Ethical Healthcare’s website and email updates about this law throughout the year and reading their publications and patient stories. Write to your legislators! This cannot be overstated. There are online templates for emails to oppose this bill, but one mustn’t stop there. Write a handwritten letter stating your opposition to this bill as well. Find out when you can visit the capitol building to meet with your lawmakers.

There is more to dying than having autonomy and control. There’s beauty, grace, and hope. Come back next week to see how dying can be just that.

[1] Revisor.mn.gov. “H.R.1358 – 92nd Legislature (2021): End-Of-Life Option.” February 22, 2021. https://www.revisor.mn.gov/bills/text.php?number=HF1358&type=bill&version=0&session=ls92&session_year=2021&session_number=0.

[2] Mike Freiberg, “The Minnesota End-of-Life Option Act: Medical Aid in Dying is a Compassionate Option for Terminally Ill Patients,” UMN Center for Bioethics, January 28, 2022. https://bioethics.umn.edu/events/minnesota-end-life-option-act-medical-aid-dying-compassionate-option-terminally-ill-patients.

[3] Revisor.mn.gov. “609.215 Suicide – Minnesota Statutes (2021).” https://www.revisor.mn.gov/statutes/cite/609.215.

 

Sarah Moon, MPH studied public health administration and policy at the University of Minnesota and currently is studying Catholic Studies at the University of St. Thomas. She works as a middle school science and math teacher at a classical Catholic school in the Twin Cities area.