On January 15, 2018, the Vermont Department of Health presented its first report to the legislature and public on the implementation of the state’s physician assisted suicide law.  The legislature had passed the law, Act 39, in 2013 and replaced it in 2015 with Act 27, which maintains Act 39 under “Oregon-style” regulations, including a requirement for biennial reporting.

The law has been in effect for four years, and the current report covers all of them.

There is little to say about this report, because it tells us almost nothing. The term “Oregon style”, like many of the euphemisms used in the run-up to the enactment of Act 39/27, is inaccurate, because this report contains much less information than the annual Oregon reports. Check them out here: http://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Pages/ar-index.aspx. It does not even tell us how many prescriptions were written and how many deaths occurred by year. True Dignity has sought, so far unsuccessfully, further information from the VT Department of Health. If this report raises questions to you, as it does to us, we urge you to call this taxpayer funded agency and ask for more information.  Contact information is available online.

Here is a brief summary of the report:

52 prescriptions have been written, and 29 people (60% of those getting prescriptions) have died after taking a prescribed lethal dose of barbiturates. 83% (43) of the patients who were approved for suicide and received prescriptions had cancer and 14% (7) had ALS; the other 2 patients (3%) were approved for suicide because of unspecified “other causes”.  Though the law (see Appendix C on the link to the report, given in the next paragraph) directs the Health Department to include the age, sex and date of death of the patients who received prescriptions, it does not.  We expect that when and if the Health Department does call us back, it will justify this information’s not being included by a clause in Act 27 that states  “as long as releasing the information complies with the Federal Health Insurance Portability and Accountability Act of 1996…”. This Act is usually called HIPAA, and it protects patient privacy. True Dignity fails to see why releasing at least the age and sex of people dying under the law would violate their privacy. No other demographic data are required to be reported.

Here is a link to the full report.  It includes the name of the person at the Health Department responsible for its preparation: (https://legislature.vermont.gov/assets/Legislative-Reports/2018-Patient-Choice-Legislative-Report-12-14-17.pdf

According to the report, “100% of the death certificates listed the appropriate cause (the underlying disease) and manner of death (natural), per Act 39 requirements.” True Dignity finds this statement outrageous, and the practice it describes, falsification of the death certificates, very dangerous.  Internally, the report struggles with this lie, listing the “mechanism” or “direct cause” of 29 deaths as “the patient choice prescription”; in realspeak, which must be avoided under the law’s provisions, these 29 people did not die from their disease but committed assisted suicide.

The pro-assisted suicide group Compassion and Choices says this report “proves” Act 67 is working exactly as it should, and also “applauds” the falsification of the death certificates.  Why does Compassion and Choices applaud medical and state lying on official documents? We think citizens should be asking.

To True Dignity, it seems self-evident that such falsification greatly enables abuse. We are told that more than 1/3 of patients receiving prescriptions in Oregon change their minds; see https://www.deathwithdignity.org/faqs/. For whatever reason, 40% of patients who got prescriptions in VT died from their disease or mysterious “other” causes.  Yet with regard to deaths that do occur, a person who suspected foul play afterwards could not get even the rudimentary information that poisoning was the true cause of death.

Add to the falsification the fact that a dead person had gone through a legal process that required him or her to announce an intention to commit suicide; such a person’s expected death would be most unlikely to arouse suspicions.  Add to the falsification and the unlikelihood of suspicions the fact that the VT law (and all other US assisted suicide laws) fail to require witnesses at the time the poison is ingested. Then add the incentive to a greedy heir of life insurance companies’ being forbidden under the laws from invoking their traditional denial of benefits after a suicide. Finally give that heir the perfect weapon: a bottle of poison with instructions for using it to bring about a person’s death. The sum of these additions is a set of conditions for all kinds of abuse, including murder.  Someone less malicious might delude himself that he had only “helped”; several people have admitted to “helping”, but no one has been prosecuted.

Assisted suicide laws, including the VT law, do not protect patient choice.  Instead they threaten it, up to its very foundation, the right to final choice of whether to live until natural death or die by a lethal overdose previously acquired.  For that reason, True Dignity finds no cause for applause or rejoicing in this report.

This horrific story of neglect and exploitation is, unfortunately, not an unusual one.  A caregiver, after neglecting his charge, filed a Medicaid claim after his death.

This caregiver was caught because he was not careful to cover up his neglect, but it would not have been hard for him to clean up and escape punishment.

The obvious danger of adding legal assisted suicide to a culture in which this can happen__and is there any in which it couldn’t or wouldn’t?__ is that none of these laws prevent a person who has gotten the lethal prescription from being alone with one other person, who may want him or her dead, either because providing care is too hard or because of a financial interest.  As Margaret Dore, attorney, has always said, “Even if the patient struggled, who would ever know?”  No one would ever investigate the death of someone who had entered a legal process that required declaring his intent to commit suicide.  In the cases in which a caregiver has admitted “helping” a person ingest the drugs, there have been no prosecutions.

Remember that all dying persons are disabled, and most severely disabled persons would meet the definition of “terminally ill” without care.  Any person who fills a prescription for suicide drugs is laying him or herself open to murder with impunity.

Here’s the link: http://www.wcax.com/content/news/Barre-Town-man-sentenced-to-4-years-for-Medicaid-fraud-448032153.html



The article linked below was first published in The National Review, then on the blog of the Euthanasia Prevention Coalition.


Wesley Smith points out that, while the NY Court of Appeals’ unanimous rejection of a constitutional right to so-called “Aid in Dying” was not unusual, the ruling made two important points.

One explicitly rejected the euphemisms used by assisted suicide advocates to pretend that a doctor’s prescribing drugs to someone and giving instructions for using them to cause death is not assisted suicide. The death, the court said, is indeed assisted suicide, which it pointed out, is prohibited by NY law. If the legislature wants to legalize assisted suicide, the court said, it will have to do it under its real name.

The other explained the difference between assisted suicide and voluntary withdrawal of life-prolonging treatment, a difference assisted suicide advocates attempt to blur. The right to decline such treatment, the court said, is not a “right to die”, but a right to reject unwanted bodily intrusions. There is no right to die, nor any right to “help” someone die.

True Dignity is overjoyed at this clear language. If people see it for what it truly is, the movement to legalize assisted suicide will surely lose any momentum it may ever have had.

For more than a year, rumors have circulated that the American Medical Association is about to change its long-held position of opposition to the legalization of assisted suicide.  Whether or not that is true, only time will tell.

A Vermont physician wrote the following eloquent letter to the AMA, expressing her vehement opposition to any softening of its opposition.  It is a perfect explanation of why, as the current position of the AMA states, “…these practices (assisted suicide and euthanasia) are fundamentally inconsistent with the physician’s role as healer.”

Here, in italics, is the letter.  Thank you, Carol Salazar M.D.  Anyone may also write the AMA at elliott.crigger@ama-assn.org.

Dear Elliot Crigger

I understand that you are the person to send comments to regarding the AMA’s upcoming consideration of withdrawing the organization’s opposition to Physician Assisted Suicide.

I am a practicing Primary Care Internist in Vermont, where sadly PAS has been legalized.  I walk with people through the end of life every day. I also have a teenage daughter.

In a world where we have seen violence, hopelessness, suicide ( especially in teens ) and addiction skyrocket, we , as physicians , will be sending the wrong message to our patients and our children who will inherit the world we leave them. What message are we sending them?

We will be telling them that autonomy trumps all… that because I want to control how I leave this world, I have the right to do whatever I want
… that there is no absolute truth…
that human life  does not matter.
That suffering should be wiped out .

Unfortunately suffering is a part of the human condition as can be seen in the literature of even ancient times . We as physicians are tasked to alleviate suffering.  We cannot always cure , but we can always comfort . We should be pouring our efforts into end of life care both at home and in Hospice institutions .

The slippery slope is real and I fear we have started our descent . We have been there before, even in our own country.  If it is ok to ask a physician to help me kill myself , it is a very short slide to extending it to the disabled and even the depressed.  The papers are FULL of stories of teen suicides and drug overdoses. It is our task to show them that we are willing to walk with them in their suffering and not give up on them.

I believe every physician should read “”The Nazi Doctors” by Dr. Ray Lifton. Proponents of PAS do not like it when I bring this comparison up. It is very painful and difficult to read because it shows how killing was medicalized and therefore came to be accepted by so many everyday physicians.

The AMA is proposing to support the medicalization of suicide… it is to be one of the “treatments” we are to offer as end of life care.

  It is a huge mistake to withdraw the opposition to PAS.  I hope that we as physicians have learned from the past and will stand firm for what is right.

Carol Salazar MD


On May 23, 2017, a US Appellate Court upheld a Consent Agreement between the state and medical professionals to protect conscience rights of professionals who oppose assisted suicide. This is a real victory and perhaps the best that could have been achieved. True Dignity cannot say that it was the victory patients in Vermont and elsewhere needed, unfortunately.  Patients have more protections than they did before this decision, but they still have far too few.

Here, briefly, is what happened.

Act 39, under which assisted suicide is legal in VT, contains protections for physicians and other medical professionals who refuse to provide assisted suicide or make referrals to doctors who will.  Two previously-existing VT laws, the Patient Bill of Rights and the Informed Consent law, however, require that “terminally” ill patients be informed about all available end of life options.  Vermont Alliance for Ethical Health Care and the Christian Medical and Dental Associations, represented by the Alliance Defending Freedom, brought a lawsuit against several “terminally” ill patients who were represented by the Vermont Attorney General’s office.  They asked for a ruling that would explicitly grant medical professionals conscientiously opposed to assisted suicide an exemption from the requirement to list it among the available“options”.

On April 5th, the US District Court for Vermont issued a ruling dismissing the lawsuit, citing “broad agreement” between the Attorney General’s office and the suing medical professionals. The Attorney General’s office had affirmed that it did not read the language of the law to require physicians to list assisted suicide among the options if a patient did not ask about it, and the medical professionals had signaled their willingness to answer patient-initiated questions and/or refer patients to other sources of information.

In its decision, the court contrasted the VT objectors’ position with that of Thomas More, who lived in what it called “a more authoritarian age”.   Perhaps the age was indeed more authoritarian, since Henry VIII did not offer More the negative option of neither agreeing nor disagreeing with the Act of Succession. On the other hand, More’s stance was perhaps more principled than that of the Vermont medical professionals.  More wrote that, were he offered the chance to remain silent, he would do so, but he refused to take the proactive step of signing the Act. The VT court decision offers a very limited right to remain silent, only up to the point at which the patient asks for information.  Once the patient has asked, the doctor is required to answer his questions with information; that seems like a proactive step to us.  Amazingly, the doctors, agreed to do that, signing the consent agreement rather than continuing to pursue the suit.

Compassion and Choices wanted complete capitulation; it appealed the Consent Agreement.  It must have soon realized it had gotten a lot of what it wanted, however; and it asked the court to dismiss the appeal. The May 23 decision was to grant Compassion and Choices’ request.

Here is the concerning language from “Civil Action No. 5:16-cv-206, Consent Agreement and Stipulation” (underlining ours) https://adflegal.blob.core.windows.net/web-content-dev/docs/default-source/documents/case-documents/vermont-alliance-for-ethical-healthcare-v.-hoser/vermont-alliance-for-ethical-healthcare-v-hoser—consent-agreement.pdf?sfvrsn=6

1.Plaintiffs and similarly situated medical providers do not have a legal or professional obligation to counsel and refer patients for the Patient Choice at End of Life process under 18 V.S.A,5281-93, the Patient’s Bill of Rights (18 V.S.A.,1871, or the Informed Consent Act (12 V.S.A. 1909(d).

2.Plaintiffs and similarly situated medical professionals have a professional obligation to provide relevant and accurate information regarding the Patient Choice at End of Life process upon a patient’s request, or if unwilling to provide the information personally, to make a referral or otherwise reasonably ensure that the patient will be able to obtain relevant and accurate information about the process.

Item No. 2, in our opinion, unacceptably requires a physician to violate his or her conscience in telling a patient where to get information about assistance in suicide.  Even more unacceptably, it violates the fundamental right of a patient to look to a doctor for care and protection.  It does not recognize that the patient may be asking about assisted suicide under pressure, perhaps pressure so subtle that he or she doesn’t even recognize it as such.  If the physician refers that patient to the internet or phone (two sources that are mentioned in various documents related to the case), that would be the equivalent of what True Dignity has always regarded as the coldest and most disinterested of responses, “It’s your decision.”   The response a patient deserves, the one we would hope VT patients would receive from their doctors, would be the proactive one given by an Oregon doctor to “terminal” patient Jeanette Hall when she asked him how to access assisted suicide under that state’s law.  He told her he would not help her, went further in telling her how it would hurt her son if she committed suicide, and urged her to get treatment for her “terminal” illness.  Today, 17 years later, she is still alive and advocating against legal assisted suicide.

True Dignity believes very sick patients deserve protection and accompaniment, not being left on their own.  This agreement does not provide adequate protections for doctors who wish to disobey this bad law, or for their patients who may desperately need them to.

Yes, the court decision is a victory.  Compassion and Choices has been telling medical professionals and patients around the state that they have to provide information to all “terminal” patients about assisted suicide as well as referrals to doctors who provide it.  If C&C had liked the agreement it would not have appealed it. It was, however, not the victory for patients that True Dignity would have wanted, and C&C’s decision to drop the appeal confirms us in our opinion.

This victory leaves patients without the possibility of the caring advocacy Jeanette Hall got from her doctor, the caring advocacy they deserve in the cold and deadly environment in which we find ourselves, an environment in which it makes perfect sense to get rid of people who cost time, emotional investment, and money.

That things could have been much worse does not mean they are not still very bad.

“The Mother Situation” https://goo.gl/7TFAuW is a darkly satirical, award winning, 7-minute film which illustrates the potential for abuse when assisted suicide is made legal. There is no question it could happen here in Vermont, where there are no requirements for oversight when prescriptions for suicide drugs are requested and filled.  When a person dies after having requested a prescription under Act 39, no investigation into the circumstances of death will be undertaken, and the cause of death will be listed as the person’s underlying illness.   This law leaves the sick and elderly vulnerable to abuse and coercion.  View this film and judge for yourself.

Eighteen months ago True Dignity ran the following story about an elderly Medicaid patient who felt pressured to request assisted suicide by caregivers in the facility where she was admitted for recovery from a fall.  The patient did not have a terminal diagnosis.  Beth Neill, the patient’s daughter, who reported the abuse to True Dignity, has since passed away.  We are running the story again, on request, in order to call attention to the dark side of Act 39, a side that is very real but unfortunately not reflected in the lopsided reporting in the mainstream media of assisted suicide deaths that are made to look almost glamorous and appealing.

From July 2013:

Here in Vermont, where physician-assisted suicide has been legal for just two years, cases of pressure are already starting to emerge, and it isn’t always family members providing the pressure. True Dignity has spoken with the family of a 90-year-old Medicaid patient who felt pressured by caregivers in the facility where she was admitted for recovery from a fall. The patient did not have a terminal diagnosis.

According to Beth Neill, clinicians at the Berlin Health and Rehab Center informed her mother at regular intervals during her 4-month stay there that she had a “right” to use Act 39, and that, “She didn’t even have to discuss it with her family.” It was the act of repeatedly bringing up Act 39 as a health care “option” that caused her mother to feel pressure, and not overt efforts by clinicians to convince her to request the lethal prescription, Neill said. However, she said her mother made it clear she wanted nothing to do with Act 39 and was disturbed that staff re-introduced the topic repeatedly.

Neill notes that her mother was, and is, in otherwise surprisingly good health for her age, and would not have qualified for Act 39, as the extended stay in Berlin Health and Rehab was strictly for help recovering from her fall.

Neill was not made aware of the situation at Berlin Health and Rehab until after her mother had already been moved to assisted living at a Northfield facility, where she currently resides. When she did hear of it, “It blew my eyebrows off,” she said.

According to Neill, the staff at the Northfield facility informed her that her mother had reacted strongly when they began to discuss care options. “Mom thought they were going to start talking about Act 39, the way they did at Berlin (Health and Rehab), and she blew up at them. She said, ‘I don’t want anyone talking to me about killing myself.’”

That’s when it came out that the staff at Berlin Health and Rehab had talked to her more than once about her “right” to request a lethal prescription. “I recalled then that my mother had been very eager to get out of there, and I had noticed that she seemed frustrated and unhappy, but I didn’t know why,” Neill explained.

Her mother told her that the staff at the Berlin facility specifically stated that Act 39 “is the law,” and in her words, “They said she could ‘off’ herself any time she wanted to.” She told her physician, who adamantly opposes Act 39, “They want me to take a bunch of pills and kill myself.”

Clearly, confusion abounds regarding the duties of medical caregivers with respect to Act 39. Vermont’s “affirmative duty to inform” under the Patient Rights Act requires that health care providers let patients know of all available treatment options, but it is not clear how this is understood to apply to Act 39 . Beth Neill’s mother did not have a terminal diagnosis and would not have been eligible for a lethal prescription under Vermont’s law.  Asked why she was informed of this “treatment option” by health care workers at his facility, John O’Donnell, Executive Director of Berlin Health and Rehab, declined to reply.

True Dignity also was unable to get answers from Berlin Health and Rehab to explain where staff received training around the implementation of Act 39and what the facility’s official policy is on assisted suicide.

We can only speculate about where some information may be coming from. In a letter to members, the well-funded pro-assisted-suicide group Patient Choices Vermont, an arm of the national organization Compassion and Choices, says that the group Compassion and Choices Vermont has been doing “extensive work educating patients, medical providers and institutions, as well as assisting individuals” to find the “resources they need.” The letter also states, “While details are still being determined, PCV will have an important role to play as health department regulations are developed (and) insurance coverage issues are dealt with.”

We do not know whether or not this group had a hand in helping “educate” staff at the nursing home where Beth Neill’s mother felt pressured to use Act 39. At present, there is no oversight mandated by Act 39 to prevent abuse, and the only other organization we are aware of with resources and staff to educate health care providers about Act 39 is the Vermont Ethics Network, which also receives funding from Compassion and Choices.

States are prohibited from using Medicaid dollars to cover costs associated with physician assisted suicide, but it is unclear whether there are provisions in the State-sponsored Green Mountain Care Medicaid to pay for drugs and doctor visits for patients requesting Act 39.

Because Act 39 contains few safeguards and almost no reporting requirements, it seems that questions will be more abundant than answers for the foreseeable future.

Thanks to a strong family support system and a personal physician who is opposed to assisted suicide, Beth Neill’s mother was able to resist pressure to consider using Act 39. What is unknown is how many other vulnerable individuals are feeling pressure today from family or caregivers, and may eventually succumb, as physician assisted suicide becomes entrenched in Vermont and aggressively promoted by those who may operate from motives at odds with the best interests of the patient.

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