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Washington's I-119.

In the beginning, Washington state's "Death with Dignity" initiative seemed charmed. Everything went right, to an extent that amazed even its most optimistic supporters. Up until the final week before the 5 November election, it appeared almost certain that Initiative 119 would pass, making Washington the first place in the world to legalize voluntary euthanasia for the terminally ill.

Volunteers easily gathered the 150,001 signatures required to place the measure on the ballot. In fact, they did so with three months to spare. Ralph Mero, president of the Hemlock Society of Washington State and the man who wrote the first draft of the initiative, collected 1,200 signatures in a single July weekend with the aid of one volunteer.

In January, I-119 supporters triumphantly presented the secretary of state with eleven storage boxes stuffed with 223,000 signatures, nearly 50 percent more than necessary. "Physician aid-in-dying," they declared, was a mandate from the people.

Money poured into 119 campaign headquarters from 26,000 individual contributors. Four thousand people sent in checks for $5 or less, many with poignant, handwritten notes attached.

Public opinion polls were positive. Surveys consistently showed that roughly two out of three Washington voters favored the concept of voluntary euthanasia. The results held, with only minor variation, for every age group and every geographic area of the state.

Meanwhile, those struggling to defeat I-119 appeared to be in disarray. The opponents' coalition, "119 Vote No!" was an uncomfortable union, bringing together born-again Christians, various right-to-life groups, the Catholic Church and - belatedly - the Washington State Medical Association. Members bickered over details, had little money, no apparent campaign strategy and, in short, appeared to be fighting a losing battle. One week after Labor Day, less than two months before the election, the 119 Vote No! campaign office did not even have a listed telephone number.

Yet when the votes were counted, Initiative 119 failed by a decisive margin, having received just 46 percent of 1.5 million votes cast.

The story of the I-119 is a fascinating one because it tested, for the first time, what would happen if this most difficult of ethical dilemmas were put to a popular vote. Campaign strategists found themselves in uncharted territory, faced with the task of reducing complicated philosophical arguments to compelling sound bytes.

The campaign was gripping because it was argued with such urgency and passion. Both sides campaigned with the heartfelt conviction that they were making a stand for the good of mankind. Each side viewed the other with a degree of contempt and disbelief that is remarkable in American politics. Some of the most moving arguments were literally made from the deathbed.

The arguments were washed in the glare of television lights from as far away as Japan, Germany, and Brazil, and brought a steady flow of ethicists, theologians, high-profile doctors, and assorted extremists from outside the state. As much as anything else, the final outcome of the election turned on external circumstances: a best-selling book, a damning suicide note, the wealth of the Catholic Church, and the excesses of a deranged doctor.

Why Washington?

During the campaign, it was sometimes suggested that Initiative 119 was the product of some powerful cabal, that cunning strategists of the international right-to-die movement had targeted Washington as the most likely place in the world to insert the thin end of the euthanasia wedge.

That wasn't the way it happened. Members of the local Hemlock Society were instrumental in getting things moving, and the language of the initiative was clearly influenced by the Hemlock-sponsored referendum in California, which failed to gather enough signatures to appear on the ballot there in 1988. The Washington effort was a home-grown crusade powered by individual commitment to what was viewed as a righteous cause. If there had been a cabal, however, their choice of places and their timing could hardly have been better.

Washington is one of only twenty-two states that have an initiative process, and because of its relatively small population (five million), it is one of the most accessible. Not only that, but Washington voters have a reputation as mavericks, ready and willing to cross conventional lines. The right to self-determination is fiercely depended. Also, organized religions have a looser grip in the Pacific Northwest than in any other part of the country. Surveys consistently show Washington to be one of the two or three least churched states in the country. And, according to a recent City University of New York study, only 19 percent of Washingtonians consider themselves Catholic, well below the national average of 26.2 percent.

The timing of Initiative 119 was what created the real opportunity, however. The proposed legislation came at a time when the public had begun to experience great frustration with the state's existing right-to-die law, the 1979 Natural Death Act. That law was regarded as a bold step when first passed, but has since has come to be regarded as overly cautious and ambiguous.

General agreement that change was necessary enabled the sponsors of I-119 to present aid-in-dying not as a stand-alone issue but as part of a package deal, one of several changes that constituted a general makeover of the act. In rewriting the existing law, they were able to incorporate features that the state's medical community had been trying to get through the state legislature for three consecutive years without success.

In addition to the new section authorizing "aid-in-dying" to competent, terminally ill adults, I-119 would have expanded the state's definition of "terminal condition" to include patients with as long as six months to live and also those who were not actually about to die, but in irreversible comas or persistent vegetative states. It also would have specifically included artificial nutrition and hydration among life-sustaining procedures that could be refused in living wills.

Opponents of 119 complained that Washington Citizens for Death with Dignity, the sponsors of the initiative, were trying to pull a sleight of hand, that they wanted to slip in the euthanasia option under the cover of more politically acceptable changes.

The euthanasia portion of I-119 was in fact underplayed during the signature drive and during the first few months of the campaign. The petition campaign workers circulated said, "Death with Dignity" in bold letters across the top, and "A Voluntary Choice for Terminally Ill Persons." A soaring dove was silhouetted in one corner. The word euthanasia was never used.

The official ballot title - the language voters would confront in the voting booth - also was ambiguous and sanitized. "Shall adult patients who are in a medically terminal condition be permitted to request and receive from a physician aid-in-dying?" The question was straightforward enough for those who knew that "physician aid-in-dying" meant that the doctor would kill the patient. During the early stages of the campaign, however, by no means everyone did.

In setting the stage for 119, supporters concentrated on selling the entire 119 package, spending a great deal of time and effort making arguments about living wills and tube feeding, which virtually no one disputed. They proceeded on the assumption that the more completely people understood the pain and frustration of the terminally ill, the more likely they would be to support all efforts to give control to the patient. The task, as they understood it, was education. Toward that end, they organized an ambitious "speakers' bureau" to take their arguments to groups of opinion setters. They organized hundreds of educational forums, usually in the form of debates, in which right-to-die issues were presented to lawyers, doctors, service clubs, businessmen, and church groups. In the final month before the election, 150 such forums were conducted in the Seattle-Tacoma area alone.

The Medical Community's


Throughout these debates Washington's doctors, to whom many looked for guidance on the aid-in-dying question, appeared to be unable to make up their minds. The campaign group, "Physicians for Yes on 119," was matched by an equally active and vocal "Washington Physicians against 119."

The official policy-making body of the state's physicians, the Washington State Medical Association, voted overwhelmingly to oppose the initiative at two consecutive annual meetings of delegates, in September 1990 and again in September 1991. Following the first vote, however, the delegates were criticized by some members for having taken a stand on such a controversial issue without first having polled individual doctors.

Confident that poll results would justify their stance, the WSMA surveyed doctors statewide in February 1991, choosing a random sample of 2,000 of the organization's 7,000 members. Of those polled, 1,105 doctors responded.

The results were mystifying. Seventy-five percent of physicians said they did not believe they should have the legal right to give a terminally ill patient a lethal injection. Sixty percent said doctors should not be allowed to prescribe a lethal dose of medication to be self-administered by the patient. And 75 percent said they would not be willing to be personally involved in aiding a patient's death. Yet in answer to the question, Should the WSMA support or oppose Initiative 119? respondents were split down the middle, with 543 doctors saying the WSMA should support the initiative, and 562 indicating the organization should oppose it.

The leadership of the WSMA refused to accept the poll results as evidence that half the doctors in Washington supported the concept of physician aid-in-dying, arguing that doctors were willing to hold their noses and accept aid-in-dying only as a way to achieve other, less extreme changes in the law. Others argued that the survey was flawed, or, more convincingly, that doctors simply hadn't read the initiative and didn't understand what was in it.

As is common in initiative campaigns, the opposition mounted little organized resistance until after Labor Day. At that point Citizens for Death with Dignity had raised more than twice as much money as 119 Vote No!, and much was made of that disparity. Those opposed to the initiative portrayed themselves as underdogs, complaining about the powerful "death juggernaut," that was pushing the initiative on the unwary citizens of Washington state.

But as the election drew nearer, money flowed into the 119 Vote No! campaign in a steadily increasing stream from right-to-life groups and the Catholic Church, much of it from outside the state. The Catholics launched an all-out attack, not only with money but also from the pulpit and in the streets, organizing drive for new-voter registration, making absentee ballots available, and urging donations. After Seattle Archbishop Thomas Murphy made a national appeal, $340,000 flowed into the No! campaign from five archdioceses (Philadelphia, New York, Los Angeles, Portland, and Seattle) and fifty-three different dioceses in thirty states.

To no one's surprise, television was where most of the dollars went and where the most decisive battles were fought. The thirty-second commercial format was not kind to either side. Citizens for Death with Dignity stuck to the personal choice theme, and in most of their television spots they used the basic testimonial format: terminally ill cancer patients stared into the camera and made a case for their right to choose "a humane and dignified death."

The opponents stayed well away from the personal choice argument and, on television at least, never mentioned "the sanctity of life." Instead, they concentrated solely on the issue of public safety, attacking the proposed law as dangerous. Over and over, they repeated the refrain: "Initiative 119 has no safeguards."

Strictly speaking, that was not true. Initiative 119 did have safeguards. The question was, Are the safeguards adequate? As written, I-119 emphasized that aid-in-dying would have to be completely voluntary on the part of both doctor and patient, that in order to qualify, a patient would have to be conscious, competent, and request aid-in-dying in writing. It required that two physicians, one of them the attending physician, would have to certify that the patient had six months or less to live.

The No! campaign hammered away at each of these points, arguing that there was no guarantee the law would be followed. There was a danger, they warned, of patients being killed against their will, either because of misguided doctors, because killing would be a cheap alternative to expensive terminal care, or because patients would be coerced by impatient or greedy family members.

The opposition ads relied heavily on overstatement: a motherly hospice nurse said, "Initiative 119 would let doctors kill my patients." Another nurse claimed, "In Holland, the only place where doctors are permitted to put patients to death, thousands were killed or allowed to die last year alone - without being asked," and in a third ad, "An eye doctor could put you to death."

One particular memorable anti-119 commercial featured an elderly farmer strolling through a field, chatting about his own impending death. "The problem with Initiative 119," he drawled, "is it gives some people too much authority to take someone else's life ... It's more or less a right to kill." As the word DEATH flashed on the screen, in white letters on a black background, he concluded, "There should be now law to take your life away from you." These ads horrified the Citizens campaign strategists, not only because they regarded them as blatant lies but because there seemed to be no effective way to neutralize them.

Throughout the campaign, I-119 was closely linked in the public mind to the Hemlock Society, and by association, to that organization's executive director, Derek Humphry. In October, Humphry's latest book, a remarkably explicit suicide manual called Final Exit, became a runaway bestseller. Humphry hit the national talk-show circuit, selling the book. In those shows and in newspaper stories, he came across as a less-than-entirely prudent advocate.

At the height of the Final Exit business, Humphry's ex-wife, Ann Wickett Humphry, killed herself with an overdose of drugs. In a suicide note, she blamed Humphry for psychological cruelty that drove her to death. She also claimed that Humphry had actually smothered his first wife Jean, rather than merely providing her with lethal drugs, as he claimed in his first book, Jean's Way.

Humphry vigorously denied Wickett's charges, going so far as to take out a quarter-page ad in the New York Times to publicize his ex-wife's mental problems. Nevertheless, he came off badly in the affair. And so did I-119.

Then, just eleven days before the election, Dr. Jack Kevorkian resurfaced. The Michigan pathologist who created such a stir with his "suicide machine" a year earlier, struck again. On 24 October he assisted in the suicides of two women, neither of whom was terminally ill, in a Michigan cabin.

Up until then, Washington polls had shown an unusually large percentage of "undecideds" on the 119 issue. During the five days of nonstop media coverage on Kevorkian, public opinion analysts at Washington Citizens for Death with Dignity watched those voters scramble in droves to the no side.

On election night, I-119 campaign workers gathered in a ballroom at the foot of Seattle's Queen Anne Hill to watch the returns. Minutes after the polls closed at eight o'clock, the first precinct reported in with a substantial majority for I-119. With a total of 200 votes cast, 70 percent were yeses. The crowd, bursting into applause, could not know that was to be the last time the initiative led all night.

Derek Humphry was in the crowd, having travelled north from National Hemlock Society headquarters in Eugene, Oregon, to be on hand for the vote-counting. Late in the evening, when it became clear that 119 would fail, Humphry struggled to put the impending defeat in a positive light. "Win or lose, this has been a valuable exercise," he said. "This is part of a process. Next time it will be easier."

Perhaps. But if there is a next time, it almost certainly will not be in Washington state, and it is difficult to imagine a more favorable setting. The clearest lesson of the 119 campaign seems to be that, as an opposing campaign tactic, creating fear is both easy and effective. Recognition of that fact is not likely to advance the aid-in-dying cause.

New California Initiative

Physician aid-in-dying may once again be put to the vote, this time in California, if efforts to put a new death with dignity initiative on the state ballot in November succeed. Californians Against Human Suffering are campaigning vigorously to collect the requisite 387,000 valid signatures.

The proposed California Death with Dignity Act, like its unsuccessful predecessor, the Humane and Dignified Death Act (which failed to qualify for the 1988 ballot), would allow competent, terminally ill patients to request and physicians to administer "aid-in-dying to end their life in a painless, humane and dignified manner." Under the provisions of the act, such requests must be "enduring" and voluntary, and must take the form of a revocable written directive signed by two unrelated witnesses. Directives would become part of patients' medical records. Physician who provide assistance would be protected from criminal, civil, and administrative liability. Those who, for reasons of conscience, cannot accede to a patient's request must transfer the patient's care.

The new Death with Dignity Act incorporates stricter safeguards than Washington's Initiative 119. In particular, residents of skilled nursing facilities may not execute such directives unless one of the two required witnesses is a patient advocate or ombudsman appointed by the state for this purpose. The initiative would also require that hospitals or other health care providers who honor a directive report the patient's age, type of illness, and date the directive was carried out to the Department of Health and Human Services, while maintaining strict patient confidentiality.
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Title Annotation:Dying Well? A Colloquy on Euthanasia and Assisted Suicide; includes related article on new California Death with Dignity Act
Author:Carson, Rob; Crigger, Bette-Jane
Publication:The Hastings Center Report
Date:Mar 1, 1992
Previous Article:Paternalism no problem.
Next Article:Voluntary active euthanasia.

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