Busy day in Concord starts with end-of-life bill

End-of-life; smoothing the way for telemed abortions; making oral contraceptives available over the counter (and maybe undercutting the HHS mandate on the way); demanding transparency from insurers: welcome to Tuesday at the State House in Concord. Hearings will begin this morning on these bills.

HB 151:  establishing a committee to study end-of-life decisions

In 2013, Governor John Lynch vetoed a bill to set up a committee to study “end-of-life decisions.” The bill had originated as a straight-up assisted suicide bill before being amended into what the sponsor hoped would be a noncontroversial baby step forward. I noted at the time that Rep. Robert Rowe was not fooled. He spoke to his colleagues briefly and forcefully during the floor debate, saying “The total thrust of this bill is euthanasia.”

New session, new sponsor: House Bill 151 has been brought forward by Rep. Larry Phillips (D-Keene). The bill has no co-sponsors at this time. Rep. Phillips wants to commission six state representatives and one state senator to study end-of-life decisions, with the bill to become effective upon passage and a committee report due November 1.

The committee, should it be formed, would be tasked with (but not limited to) “investigating the positive and negative effects of legislation in states that have enacted aid in dying laws, innovation practices of other states, specifically Minnesota, Wisconsin, and California, how to encourage careful and responsible deliberation about this complex and emotional issue, and any other matter the committee deems relevant to its objective.

Rep. Rowe had it right in 2013. His words are just as apt now.

SB 36: making oral contraceptives available without a prescription

This one comes from Senator Andy Sanborn (R-Bedford). Interesting. I had two thoughts when I heard about this bill: Culturally, it’s wretched. Politically, it has one potential good effect: it could weaken the Obamacare contraceptive mandate.

If oral contraceptives are available without a prescription – behind the counter, under the terms of Sen. Sanborn’s bill, rather than over the counter – they won’t be covered under anyone’s health insurance prescription drug plan. Anyone wanting to consume an oral contraceptive would pay for it herself, or receive it under a Title X family planning subsidy. That’s how things stood before August 2012, when the creaking leviathan known as Obamacare began imposing what was then known as the HHS mandate.

Obamacare classifies suppression of female fertility as a public-health priority, to the extent of treating it as “preventive care.” We are all therefore mandated to pay for it in our health insurance plans, and most business owners are required to include it in any health insurance plan offered to employees, irrespective of religious beliefs about the immorality of contraception and abortion-inducing drugs. Remember, the Hobby Lobby case was very narrow. Many other Americans are still in court defending their right not to pay for someone else’s contraception.

If SB 36 were to pass, it wouldn’t affect shots or implants or IUDs. The contraceptive mandate would still exist, as long as there’s public policy in place that treats women’s fertility as something to be prevented. Title X would still exist, with tax-funded block grants going to states for “family planning” excluding surgical abortion.

I wonder what non-prescription birth control pills would mean for agencies like Planned Parenthood. Is it safe to assume that the cost of the drugs would go down, if they were available without prescription? Would the agencies pass on those savings to clients? Would they not need quite so much Title X money to do the same job they’re doing now? Or would the agencies shift to a medical model relying more on implanted drugs, keeping the mandate as a cash cow?

Let’s see who shows up to testify on this one.

SB 42: relative to employee notification of contraceptive coverage

If SB 42 passes, and if you’re an employer who offers health insurance as an employee benefit, you have to tell your employees about contraceptive coverage and what contraceptives might not be covered.

“Such notice shall be prominently displayed on the face of any written application for employment …[and] where such employer maintains a publicly accessible Internet webpage that provides information on prospective employment opportunities, the employer shall provide clear and conspicuous notice on the webpage as to whether the employer provides contraceptive coverage and, if so, whether such coverage includes some, but not all, contraceptive drugs and devices or their generic equivalent approved by the FDA.”

Fine. We’ll inch toward transparency in our insurance policies even if we have to rely on Hobby Lobby opponents to do it. This bill is sponsored by Senators David Pierce (D-Lebanon) and Martha Fuller Clark (D-Portsmouth), who are fuming at the very narrow victory won at the Supreme Court by the owners of Hobby Lobby, who objected to covering four out of the twenty methods of FDA-approved contraception.

Of course, transparency isn’t the sponsors’ goal here. It’s simply a means to a couple of ends. One end is to embarrass employers who would rather stay out of their employees’ sex lives. Another is to make abortion and birth control indistinguishable and equally desirable under public policy. The owners of Hobby Lobby objected only to helping provide four methods of “birth control” that are known to induce abortions. The Supreme Court OK’d that narrow exception for that one type of business (closely-held). That’s apparently going too far, in the eyes of Senators Pierce and Clark.

SB 84, relative to the definition of “telemedicine”

Telemedicine – the use of electronic media like video conferencing for the purpose of diagnosis, consultation or treatment – is going to be extraordinarily valuable. It holds great promise for mental health treatment, among other things, and mental health treatment was the focus of a New Hampshire study committee on telemedicine. SB 84 has been drafted in the wake of the committee’s recommendations.

A New Hampshire telemedicine law will be just as useful for abortion providers who have been impatient to start dispensing abortion-inducing pills remotely. Telemed abortions are already being done elsewhere in the country. It’s neither good medicine nor good social policy to suppress telemedicine simply because abortion providers want to use it. As with SB 36, though, it’ll be interesting to see who testifies on this one.


“Alleviating suffering is different from eliminating the sufferer”: confronting the Massachusetts assisted-suicide bill

Undeterred by the defeat of a 2012 ballot initiative promoting physician-assisted suicide (PAS) in Massachusetts, legislators there are working to enact PAS via legislation. I went to Boston today to listen to the hearing on the bill, H.1998. I stayed only two hours, but that was long enough for me to see that the people who want to legalize PAS are relentless. Are those of us opposed to doctor-imposed death just as determined? We’d better be.

Today was one of those days when my social media skills fell flat. I tweeted throughout the hearing – or so I thought. I found later that the tweets never got past my valiant little phone. They’re all unsent drafts. They actually serve as decent notes.

At MA state house for assisted suicide hearing. Many people sporting “My life my choice my death” stickers.

Massachusetts Citizens for Life sent an email this morning claiming that pro-PAS groups were busing in supporters. I can’t verify that, but I can say that the crowd of more than 200 people included an awful lot of folks with those identical green stickers.

Committee chair cautions all to be respectful of those speaking on this “sensitive topic.”

Respect wore thin after the first 90 minutes at this hearing with the Joint Committee on Public Health. There were people testifying that there’s nothing compassionate about killing, and then there were people objecting to anyone saying that. The presiding officer, Rep. Jeffrey Sánchez (D-Jamaica Plain), finally made it clear that he didn’t want anyone accusing anyone else of lack of compassion.

Rep. Sánchez also made it clear that he favors the bill, although he has “struggled with it.”

MA Medical Society testifies in opposition to physician-assisted suicide. “Incompatible with physicians’ role as healer.”

Former Massachusetts Medical Society president Dr. Barbara Rockett, speaking for MMS, was brief and blunt in opposition to PAS. “This is incompatible with the physician’s role as healer.” She went on to say that MMS opposes legislative tinkering with the practice of medicine, which she sees in the bill’s assorted “requirements.” Dr. Rockett was active in the defeat of the PAS ballot initiative, saying during that campaign, “To substitute physician-assisted suicide for care represents an abandonment of the patient by the physician.” 

Interesting: one of the bills today would prohibit health care pros from participating in the torture/abuse of prisoners. Drs testify re Do No Harm ethic. Will same drs apply that Do Not Harm ethic to PAS?

H.1998 was one of twenty bills on the agenda, although it drew most of the day’s testimony. Two other bills, one from each chamber, would “prohibit the participation of health care professionals in the torture and abuse of prisoners.” Physicians and psychologists provided vivid and compelling testimony favoring such a ban. Several of these professionals related how the co-opting of medical professionals in the torture of prisoners violates the “do no harm” ethic. These same professionals did not apply that ethic to H.1998, and in fact were silent on PAS today.

state rep Adkins (sp?) supports PAS, comparing force-feeding against patients’ will to torture.

Rep. Cory Atkins (D-Concord) came out in strong support of PAS, asking “who is in charge of us at the end of life?” She evoked the specter of force-feeding of dying patients against the express wishes of those patients, calling it torture and saying that families who insist on feeding dying loved ones do so “to make themselves feel better.” Chairman Sánchez found nothing objectionable in that declaration, judging from his silence as his colleague spoke.

One could make the case that a dying person’s family members might support PAS “to make themselves feel better.” Or would that be an uncivil thing to say? Would the chairman have been moved to interrupt someone making that claim? I can only guess.

Rep. Atkins declined to say who’s force-feeding a patient if the patient has an advance directive barring such an activity. Massachusetts already has a durable power of attorney/advance directive law on the books. If the kind of force-feeding Rep. Atkins describes is happening, it’s happening in violation of the law. And if medical professionals and law enforcement officials can’t handle a written order regarding feeding, that gives me no confidence that a PAS law full of “safeguards” would promote patient safety.

If Rep. Atkins is right about force-feeding going on in violation of patient wishes, that means the durable power of attorney law is being ignored. Her colleagues did not question her about that today.

MACLU supports assisted suicide bill; right to be free of “unnecessary suffering.”

Carol Rose of the Massachusetts Civil Liberties Union testified in support of PAS, immediately after testifying in support of the anti-torture bill. She said we all have a right to be free from unnecessary suffering, which makes me wonder what “necessary” suffering looks like in the CLU’s eyes. She also warned of “scare tactics” from PAS opponents. She claimed that the experience in Washington and Oregon, where PAS has been legal for years, shows that abuse of the system Just Doesn’t Happen. Besides, she said, the state has no business being involved in end-of-life decisions.

Her assertion that abuse doesn’t happen requires taking a lot on faith. The Patients Rights Council has tracked euthanasia measures all over the world, including the ones in effect in the U.S. Their information about Oregon’s PAS law includes a warning about incomplete record-keeping regarding acts taken pursuant to the law.

One legislator, whose name I unfortunately did not catch, questioned Ms. Rose: if the state has no business being involved in end-of-life decisions, why do you want the state involved in encouraging suicide? Ms. Rose’s answer was as chilling as it was simple: if the patient is terminally ill, then it’s not suicide for the patient to take her own life.

Her answer was not an aberration. A retired psychiatrist, who is also a former medical director of a hospice, echoed her thought, saying PAS is “not suicide as we understand it.”

Several pro-assisted suicide people testifying re agony of watching a parent die. I’ve been there. Not easy.

Not easy, indeed. Yet PAS is supposed to be about the patient, not the patient’s loved ones, if I understood the bill’s supporters today.

Every supporter of H.1998 who was not affiliated with a group testified about a loved one’s suffering and death. I saw today, and I’ve seen at similar hearings in my own state, that people promoting suicide have no reluctance to tell their stories. People opposed to state-sanctioned, physician-aided death will learn to speak up about their own experiences and those of their loved ones – or else they will lose the political argument, plain and simple.

MCFL: bill encourages lying on death certificate by saying “suicide” won’t be listed as cause of death in PAS cases.

I’m glad Massachusetts Citizens for Life got this into today’s record. This is a feature of every assisted-suicide bill I’ve ever read, including those that have been introduced in my own state: deaths pursuant to PAS are not to be listed as “suicide” on the patient’s death certificate. Whose delicate sensibilities are offended by recording the truth? Does the medical community honestly think that such subterfuge will prevent distrust between patient and provider?

 “Alleviating suffering is different from eliminating the sufferer.” – John Kelly

“To have power of life and death over a person is criminal.” – Kate Ryan

Powerful testimony against PAS came from John Kelly of Second Thoughts, a disability-rights advocacy group, and from Kate Ryan, an advocate for people with autism. I tweeted (well, thought I tweeted) their best lines, which beautifully crystallize the passionate concern for human dignity shared by opponents of H.1998. In their own ways, Kelly and Ryan defended inherent human dignity, not a dignity that depends on being healthy or physically independent or mentally intact. Kelly actually got the attention of the committee, and most of the people in the room – I was sitting in back and could see this – when he started his testimony by taking legislators to task for not making sure sidewalks were cleared around the State House. “That kept some of our people from getting here today.”

#boom, as the social-media saying goes.

Also supporting the bill: Compassion and Choices, a PAS-advocacy group active nationwide. No surprise. C&C sends a lobbyist to any state contemplating end-of-life legislation. Oh, that name! The euthanasia movement has come a long way (and learned a lot about marketing) since the days of Derek Humphry’s Hemlock Society. The C&C lobbyist today said that the ballot initiative failed because PAS opponents outspent pro-assisted-suicide forces 5 to 1  on a “media blitz” of misinformation. (That’s the same figure claimed by assisted-suicide supporters the night the ballot initiative failed, before the final expenditure reports had to be filed.) He considers the legislative route for PAS to be a more considered, more measured way to get the job done.

Keep the public at a distance, in other words. The Massachusetts legislature and governor may yet manage to do just that.

So what’s on your state’s agenda?

Five reasons (so far) to watch NH legislators in 2014

January’s still three months off, and as of this writing 355 proposals for bills have been filed in Concord. This is a simple list of sponsors and topics; the texts of the bills haven’t been prepared yet.

Abortion. Rep. Kathleen Souza (R-Manchester) is proposing bills regarding licensure of abortion facilities and collection of abortion statistics. An aside: A post I wrote recently mentioning the lack of a stats bill in NH drew an objection from a reader, who said I had no statistics about abortion’s effect on women to support my concern that we need statistics to measure abortion’s effect on women. Got that?

Death penalty. Rep. Robert “Renny” Cushing (D-Hampton), whose father was murdered in 1988, is once again introducing a bill to repeal the death penalty in New Hampshire. I oppose the death penalty, after years of being ambivalent about it. I have attended hearings on death-penalty bills before, and I am always struck by how many abortion advocates oppose the death penalty and how many defenders of the unborn support it. Time after time, the most consistent voice, defending the right to life for preborn children as well as for condemned murderers, comes from representatives of the Catholic Diocese of Manchester.

Another Dominick’s Law? Rep. Leon Rideout (R-Lancaster) has an LSR to “include ‘fetus’ in the definition of ‘another’ for the purpose of certain criminal offenses.” Another fetal homicide bill, perhaps? If so, recall that in 2012, only a last-minute desperation move by abortion advocates prevented an override of Gov. Lynch’s veto of a similar bill.

Suicide. Rep. Donna Schlachman (D-Exeter) wants to see suicide prevention programs in schools. Rep. Tim O’Flaherty (D-Manchester) has submitted a pair of LSRs relative to suicide, including one to create an affirmative defense for a person who aids or assists someone to commit suicide. Interesting juxtaposition there.

Establishing a committee to study end-of-life decisions. Rep. Charles Weed (D-Keene) is back. Recall what one of his colleagues had to say the last time Weed sponsored an “end-of-life” bill.

Stay tuned for more clues about the 2014 session. At this point, no LSR has been posted online about repealing New Hampshire’s parental notification law.

“Clarifying” life-sustaining care in NH: don’t take water for granted

With little fanfare, a bill making a significant change in the definition of life-sustaining care is now under consideration in Concord. I attended the hearing to find out what was behind the legislation. As has been the case time & again on the end-of-life bills I’ve monitored through the past couple of decades, the most interesting remarks didn’t come from the sponsor. Also, once again, I heard medical and social-service professionals blur the distinctions among terminal illness, “permanent unconsciousness,” and non-terminal physical disability.

Calling New Hampshire’s advance directive law “cumbersome,” Sen. Peggy Gilmour (D-Hollis) introduced SB 170 to her New Hampshire Senate colleagues on the Health, Education, and Human Services committee earlier this week, with support from four co-sponsors. According to the bill’s formal analysis, it “clarifies the definition of life-sustaining treatment to include nutrition and hydration for purposes of an advance directive.” Gilmour, a nurse, said “Our [the legislature’s] job is to make this a process that promotes advance planning. This bill clears up confusion.”

Under the current state law regarding living wills and durable powers of attorney for health care, “medically administered” food and water are treated separately from all other forms of medical care and life-sustaining treatment,  Food and water have been considered, well, normal. SB 170 would change that, rolling food & water into the same category as dialysis and mechanical respiration.

Testifying in favor of SB 170 were a physician, an Episcopal priest, and the executive directors of the Foundation for Healthy Communities, the NH Hospice & Palliative Care Organization, and the NH Council on Developmental Disabilities. All had the same message: SB 170 would simplify, clarify, and reduce confusion over the existing law. No one testified as an individual patient or patient’s family member.

Rep. Lenette Peterson (R-Merrimack) was not won over. She called SB 170 “bait and switch to the people of New Hampshire, who think of food and water as ordinary treatment. Will insurance companies refuse to cover nutrition and hydration [as part of end-of-life care] if it’s considered ‘life-sustaining’ treatment?” She added that the bill is a danger to people with disabilities who rely on so-called artificial feeding, even though they are not terminally ill.

Not so, said Sen. Gilmour. People with disabilities who are not terminally ill “should not be affected by this. [Their] choices are not being taken away.”  So far, so good. But then the Episcopal priest gave the game away, in a manner of speaking. This Canon, an obviously-compassionate man of over 40 years experience in pastoral ministry, said of end-of-life planning that people “don’t really understand the complexity of this issue” and “they mention Terri Schiavo.”

The good priest was present to endorse SB 170 and its “clarification.” Would that really help people understand the complexity of the issue? Do he and his parishioners who mention Terri Schiavo understand that while she had brain damage, she was not terminally ill, but instead died of starvation and dehydration nearly two weeks after being deprived of food and water? For a review of Schiavo’s long illness and eventual court-imposed death, see here.

And then there was the testimony of Carol Stamatakis of the NH Council on Developmental Disabilities. She dismissed Rep. Peterson’s concern about how people consider food and water to be ordinary care. “From a legal and constitutional perspective, food and water is medical treatment.” She did acknowledge that “for some people, this is a religious distinction,” and she was sure that such religious beliefs were accommodated under SB 170.

I suppose I should be relieved to have my religious beliefs accommodated in Concord. But think about what I heard. It’s OK for me to think that nutrition and hydration are ordinary and even palliative, as long as I understand that the medical professionals know better. Hmmm.

Also, what’s the result of the “confusion” mentioned by the bill’s supporters? Is it just that not enough advance directives are being signed? Perhaps people aren’t signing because they don’t want such a document. Some of SB 170’s supporters speculated that this is all because people are in denial about death. I caught a whiff of the-pros-know-best, which is a far cry from respecting a patient’s wishes.

Shortly after the hearing, I forwarded my notes to some friends and colleagues familiar with the end-of-life landscape from personal, medical, and political angles. Response was quick and unanimous: this bill means trouble for people with disabilities who can’t speak for themselves. I was given access to a message that has since been sent to the committee by Diane Coleman of Not Dead Yet, a national grassroots disability rights group. Coleman gave four reasons for keeping nutrition and hydration separate under law from other life-sustaining treatments.

  • Many non-terminal conditions related to swallowing prevent safe oral ingestion of food and fluids.
  • People who need tube feeding on a long-term basis, for example people with brain injury or a developmental disability, are disabled under law, and protection of this group is subject to a variety of laws to prevent discrimination.
  • Many people with an uncertain prognosis may depend on tube feeding and intravenous fluids temporarily, but then recover. Cutting off fluids at that stage of uncertainty creates a self-fulfilling prophecy of death.
  • Many people in assisted-living situations need assistance to eat orally, but may be insufficient staff to handle the feedings. In some settings, tube feeding is used for that reason alone.

Coleman concluded that life support has become “an increasingly pejorative term,” and said that sweeping food and fluids into that category actually undermines informed consent. She does not support SB 170.

Sen. Gilmour’s bill, if it respects religious beliefs as Ms. Stamatakis says, will let me specify that I do not wish to be dehydrated to death.  It is profoundly troubling to me that I’d have to put that in writing in order for an end-of-life “health care” provider to know what to do.

As of today, no date has been set for a committee vote. Action by the full Senate will come by the end of March.

Do Not Even Think About Trying To Resuscitate

A nurse at an assisted-living facility in California followed her employer’s rules last week and stood by as an 87-year-old woman lay dying. A 911 dispatcher urged the nurse to help the woman anyway. According to station KCAL in Los Angeles (a CBS affiliate), the dispatcher asked the nurse who had made the call, “Are we just going to wait and let this lady die?” The nurse replied, “Well, that’s why we’re calling 911.”

I would like to shake that dispatcher’s hand. End-of-life care is a challenge; there was a policy at the facility in question not to perform CPR; the deceased woman, unnamed in the KCAL story, may have had a Do Not Resuscitate (DNR) order through her own choice. Even so, how can we not cheer for someone whose gut-level reaction to a moment of crisis is to care, not to abandon?

A question has been nagging at me after learning of this woman’s death: how far are we from DNR being everyone’s default medical order? More questions arise. If a facility’s DNR policy is appropriate for an 87-year-old, how about someone who’s 85? or 65? Someone has to decide if there’s a cut-off age. No-CPR was the facility’s policy. The news carries no word on whether the deceased woman voluntarily signed a DNR, or if signing one was a requirement for admission to “assisted living.” Assisted? Really?

I heard about this story briefly on NECN this morning, and I went online to find more information. There are blog posts a-plenty, but it took me some time to find the hard news story. CBS Los Angeles has already moved on to other things, with this story no longer on the home page of the web site as of this morning, although it’s available via the link above.

I was with both my parents in their dying days. My father died in a hospital, from cancer.  My mother died in hospice after two weeks in a hospital, after a fall and fracture that led to multiple organ failure. Their wishes for no CPR were clear and, in accordance with our Catholicism, absolutely appropriate. Their wishes were not dictated by a medical facility. There was therefore no hint of denial of care. I am under no mandate, religious or otherwise, to seek physical immortality for myself or for anyone else. That’s the stuff of horror stories.

Even so, I’m haunted by what we don’t know about that woman in California, who died in the hospital after being transported from the “assisted living” facility. Where was she when her heart stopped?  If the facility has a DNR policy on all residents, why even call 911? Was she dead on arrival at the hospital, or did she die sometime later?

CBS Los Angeles’ news story quoted both an attorney and a physician who were appalled by the action, or inaction, of the nurse on the scene and by the facility’s policy. The woman’s family apparently has no issue with the policy, so litigation is unlikely. Ethicists will argue about this case, and that’s about it.

Perhaps this goes on at facilities all over the country, and most 911 operators find such calls unremarkable. We are all the poorer if that’s the case. If a facility makes the decision about denial of care, that is a far cry from the patient autonomy that used to drive public policy debates about end-of-life care.