healthmedicinet

Vermont will become the fourth state to make it legal for a physician to prescribe lethal medication to a terminally ill, mentally competent patient who wants to end his life. It has also become the first state to approve the practice through legislation, instead of via a public referendum (as in Oregon and Washington) or a court decision (in Montana).

The Vermont House of Representatives approved the measure by a 75-to-65 vote on Monday night, after 17-to-13 approval in the Senate last week. Gov. Peter Shumlin has said he will sign it into law.

“It’s been a long road in Vermont,” said Kathryn Tucker, director of legal affairs for the national Compassion and Choices organization, who testified in both chambers in favor of the bill.

Supporters of what advocates call “death with dignity” (and opponents sometimes label “physician-assisted suicide”) have been introducing similar legislation in Vermont since the mid 1990s. In the only previous vote, a bill went down to defeat in the state house in 2007.

Given polls that consistently show broad support among Vermont voters, a referendum might well have passed years ago, said Michael Sirotkin, one of the lawyers representing the group Patient Choices at End of Life Vermont. But the state doesn’t permit ballot initiatives, so organizers turned to the legislature.

“I’d say this is actually a harder path, because often the public is ahead of legislators on controversial issues,” Mr. Sirotkin said.

So-called aid in dying will look different in Vermont than elsewhere, because of an 11th-hour compromise required to win over two state senators who initially voted for the proposed law, then changed their positions.

“You saw a real tension between legislators who wanted to ensure freedom of choice on this enormously personal issue and, on the other side, legislators reluctant to bring government into the practice of medicine,” Ms. Tucker said.

Therefore, when the law takes effect after the governor signs it, it will initially closely follow the Oregon model, with numerous statutory procedures and safeguards meant to protect patients against coercion or changes of heart. It adopts the same 15-day waiting period between the patient’s first request for medication and the second, for example, and requires a second physician’s evaluation.

But three years later, those requirements drop away, and a lethal prescription for a mentally competent patient expected to die within six months becomes largely a private matter between doctor and patient.

After July 1, 2016, the law will protect physicians from civil or criminal liability, and from professional misconduct charges. And it still requires informed consent, mandating that doctors inform patients of “all feasible end-of-life services,” including palliative care and hospice, and of the medication’s risks. Otherwise, it no longer mandates when or how doctors respond to requests, as long as “the patient makes an independent decision to self-administer a lethal dose of medication.”

“We view it as an elegant compromise,” Mr. Sirotkin said.

In three years, supporters hope, physicians will have become more comfortable with the process, and the data they’re required to compile on such actions will show no coercion or abuse.

The flexibility to reach this sort of compromise shows the advantage of the legislative process, Ms. Tucker said. In ballot initiatives, like the one defeated in neighboring Massachusetts last year, a statute’s language becomes locked in. And because activists on both sides have been trying to persuade 180 Vermont legislators instead of the entire voting public, the media campaign has been quieter and less expensive.

But it’s also easier for legislation to be revisited or reversed by a future legislature. “No one really believes this is going to go away,” Edward Mahoney, a religion professor and president of Vermont Alliance for Ethical Healthcare, the primary opponent of the law, told me before the vote.

Few Vermonters are likely to use the law, given the state’s size. Oregon (where last year 115 patients received lethal prescriptions) has more than six times Vermont’s population, and Washington (103 such prescriptions in 2011) is more than ten times larger. But the prospect raises strong emotions, nonetheless.

“This type of legislation has been introduced in something like 20 to 30 states and has never passed a legislature,” Dr. Mahoney told me before the vote. “They’ve had defeat after defeat, and they want a victory. That’s why it’s being pushed.”

Now supporters have that victory. “This will be something of a tipping point,” said Ms. Tucker of Compassion and Choices. “I think it will galvanize efforts around the country.”

But it might also galvanize the opposition in Vermont. “This could very well get fought all over again in three years,” Mr. Sirotkin said. For the moment, though, a small group of advocates gathered for a low-key celebration in Montpelier on Monday night.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Their Struggles and Solutions.”