“Systemic Failures and Rising Risks: How Washington’s ‘Death with Dignity Act’ Endangers Vulnerable Lives”

Lethal Non-Compliance with Washington’s “Death with Dignity Act” – Doerflinger

In his 2022 analysis, “Lethal Non-Compliance with Washington’s ‘Death with Dignity Act’,” Richard Doerflinger reveals critical failures in Washington State’s handling of physician-assisted suicide (PAS) under its “Death with Dignity Act” (DWDA). This analysis, framed from an anti-assisted dying perspective, underscores severe shortcomings, systemic abuses, and an alarming lack of oversight within the PAS framework, bringing into question the safety of vulnerable populations under such legislation. Originally introduced with the promise of robust safeguards, the DWDA appears to be more lenient than protective, with proponents now pushing to dismantle existing safeguards that were supposedly in place to prevent abuse.

1. Weakening Safeguards and the Push for “Expanded Access”

The initial passage of Washington’s DWDA in 2008 came with assurances of strict criteria, supposedly designed to prevent misuse, coercion, and safeguard vulnerable patients. However, in recent years, pro-assisted dying advocacy groups like Compassion & Choices have increasingly lobbied to relax these safeguards, presenting barriers to PAS as impediments to access rather than essential protective measures. The changes proposed include:

  • Broadening Eligibility for Prescribing Lethal Drugs: Efforts to allow non-physicians, such as nurse practitioners, to prescribe lethal drugs pose a direct threat to patient safety by reducing professional oversight.
  • Shortening or Eliminating Waiting Periods: The proposal to reduce the mandatory waiting period from 15 days to just 3 – or, in some cases, eliminate it altogether – severely undermines a patient’s chance to reconsider their decision, especially when facing mental or emotional distress.
  • Lower Standards for Mental Competency Evaluations: Permitting counsellors without psychiatric or psychological qualifications to assess patients’ judgment raises serious concerns, as such evaluations are essential to identify impaired judgment due to depression or other conditions.

Despite attempts to pass this legislation, it has stalled twice in the Senate, largely due to opposition from healthcare professionals, disability rights advocates, and public representatives concerned about the safety risks these changes would introduce. Nevertheless, the ongoing efforts to weaken safeguards highlight the persistent push from PAS advocates to expand access, even at the expense of patient protections.

2. Systemic Non-Compliance with Safeguards

The paper’s analysis uncovers alarming evidence of systemic failures in the enforcement of even the DWDA’s existing requirements, casting doubt on the efficacy of any safeguards:

  • Neglect of Psychological Evaluations: According to the Washington Department of Health, the prescribing and consulting physicians rarely request psychological evaluations, even though identifying impaired judgment is crucial to the safe implementation of PAS. This lapse is particularly concerning, as it indicates that individuals with potentially treatable mental health issues may not receive the necessary assessment to ensure informed consent.
  • Absence of Physician Oversight at the Time of Death: Prescribing physicians are seldom present when lethal drugs are ingested. This absence of direct oversight during the final stage of PAS makes it impossible to ensure that the patient’s decision is free from last-minute coercion, impairment, or doubts. Such hands-off procedures are inconsistent with a supposedly “dignified” end-of-life process, creating a situation rife with risk for the patient.

3. Missing Records and Untracked Lethal Prescriptions

One of the most disturbing findings is the prevalence of unaccounted prescriptions, with little to no follow-up or tracking:

  • Unreported and Unused Lethal Prescriptions: In 2021, Washington issued 400 prescriptions for lethal drugs. While 291 patients died after ingesting the drugs, 44 died of other causes, and 52 cases remain unresolved regarding whether the drugs were taken. This unaccounted total of up to 96 prescriptions raises the question: where are these lethal medications? Without proper tracking, the risk of these drugs falling into unintended hands – potentially resulting in unintended deaths – is high.
  • Record-breaking Numbers of Deaths: PAS deaths in Washington have seen exponential growth. The 400 prescriptions issued in 2021 represent the highest annual number to date, a more than eightfold increase since the DWDA’s implementation in 2009. This rapid rise in PAS cases suggests a societal shift where PAS is increasingly normalised and potentially viewed as a first rather than last resort for those with serious conditions.

4. Pervasive Non-Compliance in Reporting Requirements

The paper’s analysis reveals that, contrary to the claims of stringent regulation, there is widespread non-compliance with the DWDA’s reporting requirements:

  • Hundreds of Missing Compliance Documents: From 2019-2021, there has been a dramatic rise in missing documentation – the core “safeguard” of the DWDA. In 2019 alone, 41 patient requests, 39 attending physician compliance forms, 45 consulting physician forms, and 29 pharmacy records were never submitted. In 2021, 46 patient requests, 35 attending physician forms, and 47 consulting physician forms were unaccounted for. Without these records, it is impossible to confirm whether patients received the necessary consultations or mental health assessments or even had terminal diagnoses.
  • Longstanding Non-Compliance Patterns: Since the DWDA’s passage in 2009, approximately half of all cases of missing documentation have occurred in the last three years. The lack of enforcement on missing compliance forms – the fundamental basis for verifying adherence to safeguards – makes these safeguards effectively meaningless.

5. Advocacy Group Influence and Compromised Integrity

The paper raises concerns about the direct involvement of pro-assisted dying advocacy groups like End of Life Washington in PAS cases. End of Life Washington claims to have been involved in 95% of DWDA cases, despite actively lobbying to eliminate safeguards they deem as “barriers.” The significant influence of such organisations raises serious ethical concerns, as their vested interest in promoting PAS may compromise the impartiality and integrity of the process.

6. Potential Legal Violations and Ethical Failures

Given the widespread lack of compliance, The paper points out that many PAS cases technically violate Washington’s laws on suicide promotion and controlled substance use:

  • Absence of Legal Protections: The DWDA’s exemption from criminal liability only applies if all legal requirements are met. With hundreds of missing documents and non-compliance in required safeguards, these cases do not meet DWDA standards and could legally constitute suicide promotion or controlled substances homicide under Washington law.
  • Failure to Investigate: Despite these potential legal violations, the Department of Health has not referred any cases for criminal investigation or review by the medical board. Instead, these cases are reported as being “under the terms of the law,” allowing systemic non-compliance to persist without consequence.

Conclusion: A System Lacking Accountability and Integrity

From an anti-assisted dying perspective, The paper’s findings highlight Washington’s DWDA as a case study in failed safeguards, lack of oversight, and a troubling drift towards an “anything goes” approach. With missing records, weak enforcement, and advocacy groups pressing for reduced safeguards, the system appears more concerned with expanding PAS access than ensuring it is conducted safely and ethically. Vulnerable populations, particularly those who are elderly, disabled, or facing mental health issues, may be at heightened risk under such conditions, as the safeguards originally designed to protect them are continually weakened or ignored.

For anti-assisted dying advocates, Washington’s experience serves as a cautionary tale, illustrating the potential risks and ethical pitfalls of legalising assisted dying without enforcing strict, transparent safeguards. The push to expand PAS access in Washington demonstrates how quickly safeguards can erode, ultimately compromising patient safety and societal values around life, care, and dignity.