It’s fall of 2008, and a ballot measure is up for popular vote in Washington state. Supporters say the measure would expand choice and individual autonomy, while opponents warn voters to "protect the vulnerable." Catholic dioceses across the country pour money into the opposition campaign, and the measure’s supporters warn of the encroaching power of one religious group to mandate morals for all. Then the opposition ramps up fears that an individual would not even need to notify their spouse to undergo a medical procedure. Sounds like a typical abortion campaign, right? In fact, this ballot measure legalized aid in dying in Washington state.
On November 4, 2008, voters supported Initiative 1000, the Death with Dignity Initiative, by a margin of 58% to 42%. This law will allow mentally competent, terminally ill adults the right to legally access medication to end their lives. Washington joined Oregon as the second of only two states in the nation to allow aid in dying for terminally ill patients. On December 6, Montana’s First Judicial Court ruled that terminally ill Montanans have a right to a dignified death, paving the way for a third state to allow terminally ill patients aid in dying.
While the ads and op-eds arguing over Initiative 1000 could have been deployed in a campaign for a ballot measure restricting abortion access, the connections between the recently approved Death with Dignity Initiative and reproductive justice extend far beyond campaign rhetoric. Reproductive justice advocates across the country can celebrate Death with Dignity’s victory, as supporters of the initiative won a battle to define access to choice as a critical component of compassionate and high-quality health care. Washington’s initiative and Oregon’s 1994 law advance a movement for individual freedom in end of life decisions as well as an improved health care system. Although an average of under 50 people utilize this law each year in Oregon, the benefits reach all Oregonians who are struggling with terminal illness.
Numerous studies have found that Oregon now leads the nation in policies on pain treatment and hospice use. Rigorous safeguards, including strict regulations around patient prognosis, physician oversight, and patient mental competency, have led to improved training for physicians on end-of-life pain management and detection of depression. Many patients begin the process of obtaining life-ending medication and never use it, and even more patients discuss this issue with their family and friends and never seek out a prescription. The security of having this option provides patients with tremendous peace of mind. Death with Dignity laws bring the practice of physician aid in dying out of the back alley so it can be considered and regulated with transparency. Just as all women benefit from legal affirmation of their right to choose abortion or to continue pregnancies to term, so do all terminally ill Americans benefit when they are free to make affirmative choices about how their lives will end.
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Battles over accurate language are a critical dimension to advocacy for death with dignity. What do we call the practice of a physician prescribing life-ending medication to a terminally ill patient? Similar to battles over reproductive rights, both sides choose terminology that allows them to stake a claim to life-affirming policies. Opponents characterize this practice as "assisted suicide," suggesting that this practice falls outside the realm of medicine. One piece of No On 1000 literature claimed that this law would be "contrary to thousands of years of civilization." Supporters of the law use the phrases "physician aid in dying" or "death with dignity" to emphasize a patient’s right to choice on how one will die when death is inevitable and quickly approaching. By continually reiterating the word "dignity," proponents make clear that mandating a terminally ill patient to suffer until a "natural" death is coercive and lacking in compassion. Encouraged by the Death with Dignity campaign, terminally ill patients and their family members directly responded to the use of the term "assisted suicide." The term insulted them, they said; seeking an option for death with dignity while experiencing terminal illness does not resemble choosing death.
This movement shares a common primary opponent with reproductive justice work, in the Catholic Church leadership. Death with Dignity laws have been advanced by legislation or ballot initiative in 16 states, and each time have encountered the fierce opposition of the Catholic hierarchy. Initiative 1000 represents the first time in the history of this movement in the United States that proponents out-fundraised the opposition. The opposition raised only $1.6 million to the Yes on 1000 Campaign’s $4.9 million, with the largest donors being the Knights of Columbus, Seattle Archdiocese, and other Catholic dioceses nationwide. Although the media portrayed this initiative as one of the most controversial ballot measures in the country this election season, Death with Dignity garnered a high percentage of support across Washington state. Ten out of 39 counties in the state supported John McCain for President and Death with Dignity. The message that death with dignity is a personal decision clearly resonated with voters in rural and historically "red" counties.
Recognizing that aid in dying affirms individual liberties, progressive, feminist and LGBT communities have led the Death with Dignity movement, but some suggest that these communities oppose (or should oppose) aid in dying because of the potential to further marginalize vulnerable groups, such as those lacking health insurance. But statistics disprove these concerns. In the first 10 years of the Death with Dignity law in Oregon, the vast majority of patients using the law had private medical insurance (67%) or Medicare (32%). More men than women have utilized this law in Oregon, and no patient has used aid in dying without an underlying terminal illness. Any logic that politically marginalized groups must be protected from making personal decisions about their own bodies is a familiar argument for those who have examined so-called feminist anti-choice activism. Advocates of legal abortion realize that the right to privacy doesn’t mean a woman has access to comprehensive health care; Death with Dignity advocates recognize that aid in dying does not substitute for high quality medical treatment for diseases such as cancer.
A critical battleground in winning broad voter support became defining compassion. The Yes on I-1000 campaign steadfastly highlighted the personal stories of those closest to the law – terminally-ill patients, their family members, and medical professionals – to reveal patients desperate for a peaceful end to their suffering and family members who agonized with relatives requesting (illegal) aid in dying. "Both sides base support on a principled, sincere position of respect for human life," the Tacoma News Tribune wrote when endorsing the initiative. When battling the pro-life wing of the Catholic Church, holding onto the mantle of respect for human life must be considered a huge accomplishment.
The opposition even attempted to conjure the specter of the duped, unknowing spouse whose partner uses aid in dying in secret. In one commercial, actor and anti-choice activist Martin Sheen states, "Your spouse could die by assisted suicide and you wouldn’t have to know about it." Another commercial warns viewers, "Spouses don’t need to be notified if their loved one receives a lethal drug overdose," and a nurse adds, "Suicide is a mistake that can only be made once. Just think it through." Along with minimizing the rational decision-making capacity of the terminally ill, this focus on unknowing partners closely resembles the strategy of abortion foes who prioritized spousal notification laws to undermine Roe v. Wade. Spousal notification laws were swiftly implemented after abortion was legalized, and despite being struck down by the Planned Parenthood v. Casey decision in 1992, they remain a powerful symbol to anti-choice activists. In fact, any law mandating that patients disclose medical information to their family members, or enabling doctors to disclose information, would be unconstitutional. The Death with Dignity Initiative included a provision that physicians encourage patients to inform their family members of any intention to take life-ending medication; over 95% of Oregon patients using the law do tell their families. Despite these arguments, the opposition attempted to use this tactic to appeal to knee-jerk fears.
The passage of Death with Dignity affirms that all Washingtonians deserve access to a range of compassionate end of life health care options. In a time when most ballot initiatives around the country attempt to roll back reproductive and individual rights, and lawmakers dismiss bold action on such issues as too controversial, this initiative stands out as an example of citizens demanding and securing a law that they consider fundamental to their health and autonomy. The success of this campaign offers useful lessons on how to define an agenda for compassion and access to choice, and should be counted among the many victories for reproductive justice advocates on Election Day.