Hemlock Society & Foundation of Florida

Death with Dignity Act may face amendment


Western psychology professor Ethan Remmel lived with incurable cancer for more than a year. He underwent 10 months of chemotherapy, which caused fatigue and sickness that were hard to bear. He rarely felt like himself. Whenever he stopped treatment, he faced unyielding pain, said Grace Wang, Remmel’s partner and associate professor of environmental studies at Huxley College of the Environment.

At his home on June 13, Remmel ended his life under Washington state’s Death with Dignity Act. The law allows people who are terminally ill to take lethal pills prescribed by their doctors.

Remmel’s family, friends, colleagues and students came together on June 28 for a memorial at Zuanich Point Park in Squalicum Harbor. They shared stories, listened to some of Remmel’s favorite songs and read some of his favorite poems. It was his birthday. He would have turned 42.

Since taking effect on March 5, 2009, 152 people have received lethal medication under the law, according to the Washington State Department of Health. 
Washington’s law is similar to one enacted by Oregon voters in 1997. Oregon was the first state to allow people with terminal illnesses to ask their doctors for lethal medication. Lawmakers in Vermont, Massachusetts, Pennsylvania and Hawaii are considering similar measures.

“Ethan’s quality of life was so critical (to him). He wanted to watch sports and play with his sons.

These things were not happening over the last months of his life,” Wang said. “He made the right decision for him.”

Death with Dignity Act

Nearly 58 percent of Washington state voters in the 2008 election voted in favor of the Death with Dignity Act.

The law lets people living with deadly illnesses maintain some level of control over their lives, said Robb Miller, executive director of Compassion and Choices of Washington. The nonprofit organization supports terminally ill people seeking to end their lives.

“For some patients, having control improves the quality of life at the end of life,” Miller said.  
Eileen Geller, a registered nurse and president of True Compassion Advocates, a Seattle-based nonprofit corporation that promotes awareness and prevention of suicide and assisted suicide, said providing lethal medications to ill people or seniors might pressure them to choose death simply to avoid being a burden or financial burden to loved ones.

“This act ends up steering some people toward assisted suicide,” Geller said. “The solution is to create compassionate, practical and helpful resources, not hand them lethal medications.”

The term “assisted suicide” is controversial among supporters of Washington’s law. Compassion and Choices prefers the term “aid in dying.”

The Death with Dignity Act does not constitute assisted suicide, according to the text of the law. State reports are not allowed to use the term.

Washington State Senate Bill 5378, introduced during the Senate’s most recent legislative session but never brought to a vote, would require doctors to list assisted suicide as the cause of death for people who choose to end their lives under the law. Sen. Margarita Prentice, a Democrat from Renton, Wash., is the primary sponsor.

Although the bill stalled during the most recent legislative session, it could be reintroduced in the future, according to Senate rules.

Currently, when a person dies of assisted suicide in Washington, doctors are required to list a person’s underlying terminal illness on the death certificate. In Oregon, death with dignity is listed as the cause of death.

Miller said listing assisted suicide as a cause of death would make it easier for extremists opposed to the Death with Dignity Act to search public death records to find and target doctors who prescribe life-ending medication.

“The legislation is a lie, and it is for the express purpose of harassing patients and healthcare providers,” Miller said. “It’s dangerous legislation.”

Geller disagreed. She said the current law does not allow doctors to reveal a patient’s true cause of death.

“The purpose of the bill is patient safety and protection against elder abuse,” she said. “Forcing doctors to falsify death certificates isn’t honest or transparent and it isn’t safe.  It victimizes vulnerable ill people and their families.”

Living in the face of cancer

In March 2010, a pain that began in Remmel’s abdomen spread to his lower back.

It became unbearable for him, Wang said. After weeks of tests and trips to his doctor’s office, Remmel found out he had colon cancer. Wang said it spread to his bones. His doctors said the average prognosis for people with similar cancers was about two years.

He kept a personal blog for his friends and family. He updated them on his everyday life, wrote about his interests and shared feelings about his condition.

Western psychology professor Ira Hyman, a friend and colleague, was convinced Remmel’s insights on living with a terminal illness would be interesting to a wider audience. Hyman introduced him to an editor at “Psychology Today,” a popular magazine that covers mental health and human behavior. Its website hosts hundreds of blogs on a range of topics from experts in the field. Remmel agreed to become an online contributor.

He titled his blog “Living While Dying: Learning to live in the face of cancer.” He made his first post on Feb. 6.

Kristi Lemm, an associate psychology professor who was close friends with Remmel, said she was glad he decided to share his story.

“I think that it’s really helpful for people to get a perspective from someone who’s experienced what Ethan experienced,” Lemm said. “He’s a great writer, and he was very open and willing to talk about personal things in a public forum, which I think was particularly impressive.”

Remmel’s blog covered a range of topics. He wrote about treatment options, dealing with chemotherapy and how his failing heath affected his mental, physical and intellectual abilities.

Larry Symons, chair of Western’s psychology department, who was also close with Remmel, said the blog posts let Remmel express opinions on dying, living with terminal illness and the Death with Dignity Act.

“They were an excellent way to understand what he was going through,” Symons said.

Remmel wrote about difficult questions he faced as he approached the end of life.

“The big issue is how to balance the goal of maximizing quantity of life with the goal of maximizing quality of life in the treatment of terminal illness,” he wrote in a Feb. 11 entry. “With regard to my particular situation, I feel that my doctors, family and friends often weigh the first goal, relative to the second one, more heavily than I do. I don’t mean to suggest that I don’t care about my quantity of life. But I also believe that there is a point where the quality of life that can be provided does not justify additional efforts to extend life.”

Wang said Remmel did not want to stay alive if he was in so much pain that he needed sedation, or if he was too sick from chemotherapy to spend time with his children.

In his blog, Remmel first mentioned the idea to end his life voluntarily on Feb. 9. In April, he wrote that he had filled a prescription for lethal medication. He hadn’t decided if he was going to take it. It gave him great relief that he now had control over his dying process, he wrote.

In his final post on June 10, Remmel wrote he was ready to take the lethal dose. He did so three days later.

Choosing death with dignity

After Remmel announced on his blog he was considering ending his life voluntarily, he began getting e-mails from people telling him he was making the wrong choice. In an April 12 post, he responded.

“I do not view it as ‘suicide,’ because I would not really be choosing between living and dying. I would be choosing between different ways of dying,” Remmel wrote. “If someone wishes to deny me that choice, it sounds to me like they are saying: I am willing to risk that your death will be slow and painful. Well, thanks a lot, that’s brave of you.”

Wang said Remmel was never trying to be an advocate for the Death with Dignity Act. He was grateful that in Washington, people had the option.

“Had he not taken this drug, he likely would still be alive right now, but he would be so sedated that he couldn’t enjoy everything that he wanted to enjoy,” Wang said. “He’d still be alive, but he wouldn’t be Ethan. That was just really important for him to go out on his own terms.”

Symons said it was distressing at times to read Remmel’s blog, especially when he began writing about ending his life.

“As a friend, you want him to be around forever. He was choosing to make things easier for people in the long run, but I didn’t want things to change,” Symons said. “At a practical level, I understood what was going on and why he made that choice. At an emotional level, it was much harder for me.”

Washington state's stance

Of the 152 people who have obtained lethal medication under Washington state’s Death with Dignity Act, not every single one has actually died from ingesting it, according to reports from the Washington State Department of Health.

Some have chosen not to. Others have died before getting the chance. 
Thirty-six people died directly from taking legally prescribed lethal pills in 2009, according to the department. Fifty-one direct deaths were reported in 2010.

To be eligible for a prescription, a person must be a state resident at least 18 years old, be diagnosed with an illness that will cause death within six months, be mentally and emotionally capable of making the decision to end life and also be able to take the pills without aid.

After finding a doctor who will write a prescription, two oral requests and one signed and dated written request must be made. Two witnesses need to confirm a person is eligible when the written request is signed. At least one of the two cannot be related to the person, stand to financially gain from the person’s death or work in a facility where the person received care. There also must be a waiting period of at least 15 days between the two oral requests, according to the law.

Primary doctors are required to get a second doctor to also confirm a person is eligible. Doctors must offer a chance to reconsider before writing someone a prescription.

Eileen Geller, president of True Compassion Advocates, a Seattle nonprofit opposed to the law, said there is not enough oversight to ensure doctors are making the right choices when deciding if people are mentally and emotionally fit to seek death under the law.

“The safeguards are really flimsy and illusory,” Geller said. “Washington’s law doesn’t have any regulatory teeth.”

Robb Miller, executive director of Compassion and Choices of Washington, which advocates for the Death with Dignity Act, said the safeguards are effective. They prevent coercion and ensure that people do not involuntarily end their lives, he said. It is difficult, even for people seeking life-ending medication, to get through the process, he said.

Doctors can opt out if they wish, according to the law. Miller said he accepts that some doctors may be morally opposed to prescribing life-ending medication. However, he thinks doctors who opt out still have a duty to refer people seeking life-ending medication to a physician or Compassion and Choices of Washington, who will help them even though it is not required by law.

“I don’t think a physician or pharmacist should be forced to participate in death with dignity,” he said. 

Student's perspective

During spring quarter 2010, Western alumna Ashley Ruggles was ready to present her master’s thesis. Western psychology professor Ethan Remmel was her graduate adviser.

Remmel had just learned he had terminal cancer and would likely not survive longer than two more years. He was trying to keep up with his classes and students while deciding on treatment and coming to terms with his illness.

Ruggles presentation was at 8 a.m. She wasn’t sure if Remmel would be able to attend. She understood. However, when she began defending her thesis to her professors, Remmel was there. He sat through the entire thing. Then he left for a session of chemotherapy.

Ruggles said it was a testament to Remmel’s devotion to his students.

“He really took my research seriously and guided me in the right direction,” she said.

Larry Symons, chair of the psychology department, said Remmel was an excellent teacher. Symons served as a faculty mentor to Remmel. The two were close friends.

“He was very good at making students feel relaxed so they could talk about topics that were very difficult to talk about,” Symons said.

Anna Pilon, who graduated from Western in spring 2011 with a degree in psychology, was taking a child development class taught by Remmel the same quarter he began to get ill.

“It was one of my favorite classes,” Pilon said. “He just made it really comfortable, and he was just a really fascinating person.”

Jamie Betz, a 2011 Western graduate who earned a master’s degree in school counseling, was a student in the final class Remmel taught. It was a class about life-span developmental psychology, she said. They spoke a lot about death and dying. Remmel shared his experience.

“It was an honor to be in that class,” Betz said.

As the first member of her family to go to college, Betz said she had not given much thought to attending graduate school. Remmel’s focus on getting his students to think critically, his teaching style and his passion for psychology helped convince her to go for it, she said.

“He was just brilliant and real passionate for developmental psychology. It was really contagious,” she said. “He really inspired me.” 



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