missing need to be identified to help the living and more available on our website. that is aljazeera.com. the world's response to i.s.i.l. shameful according to amnesty, more on that and other stories. aljazeera.com. night hello, i'm ray suarez, it's been 20 years since oregon voters approved the death with dignity act, making it legal to end life. it survived years of efforts to tear it down. now other states, notably california are taking a look. how does the law look, and how does it look. what protections have to be guilt in to make sure the war is not abused. how do you make sure those

ending their lives are facing unending suffering with no means of recovery rather than as a means to end hopelessness, depression, inconvenience. death with dignity, it's "inside story". keep your ears open, listen to friends and family, and you'll hear a version of a good death with common hallmarks. comfortable rather than in pain, surrounded by loved ones, instead of strangers. luced, unable to say goodbye leading to a departing piece as well as those left behind. what you hear about the good death is how much it resembles falling asleep when your life is over. circumstance may dictate a

different death. kept alive by medical technology. relatives arguing about how to keep you alive when realistically nothing will keep you alive. choosing to sky involves a profound set of decisions. three states, washington, oregon and vermont have solid death with dignity laws on the books. in montreal, a similar bill is making its way through the legislature. the ability to choose a death moved into the spotlight last fall, with 29-year-old britney may nature. an aggressive brain tumor was killing maynard. she chose a dose of barr bit utes over a gruesome end. her story captured headlines, here she is in her own words. >> i can't tell you the amount of relief it provides me knowing i don't have to die the way it's describe, the way my brain tumor would take

me on its own maynard moved from california, where suicide with prescribed drugs is illegal to oregon, where it's allowed. britney's mother, who advocated for a death with dignity law in california says her daughter's everywhere. >> we agreed given her devastating brain cancer prognosis that she was fortunate to have a mother and a father and a husband who had the resources and the time and the fortitude to help her establish her new home in oregon. and this home would be the home that she would live the remainder of her life in. it would be the home that she died in since maynard's death, lawmakers in 13 states and washington d.c. introduced death with dignity legislation and according to the death with

dignity center, 22 legislators would have seen a bill proposed by the end of counter sessions. oregon had such a loss since 1997. joining me from oregon is the state health officer at the oregon health authority. welcome to the programme. if someone decides for themselves that because of their physical illness they no longer want to live, what is the process. what happens. who do you have to consult with, and how do you get the process rolling this ends with the end of your life? >> yes. so the way that i view this really is that it is a permissive law, allowing qualified patients to request a prescription and allows physicians to write the prescription, but doesn't compel anyone to participate much the steps that need to happen - this is carefully outlined in the statute - is that the patient

must be diagnosed with a terminal illness with also than six months to live. the majority of the patients have cancer. the six months or less to live is a diagnosis that is for hospice, for people to be enrolled in hospice. it is something that people at the end of life fizz earns are used to -- fizicians are used to making that diagnosis. >> does more than one have to participate in that procedure. >> there are two physicians, the first request goes to one physician, and then there must be a consulting physician or a second to make the same determination. the patient has to be 18 or older, a resident of oregon, and it's up to the physicians to determine residency. it includes things like vehicle prompt. income dam returns, voter registration. two physicians. if either

development the patient is not act make the decision there must be a psychological evaluation. the process that the patient has to have two requests separated by 15 address and a written request, it has to include two witnesses, one of whom should not have a vested interest. they both can't stand to inherit money. there can be one family member, and a desinterested party. law? >> a total of 859 people have tape the medications to hasten their deaths since 1998. >> is there a conscious clause for physicians, have you had them say i understand this is the law, but i myself would rather not be a part of it in any way.

count me out? >> again, our role is at the time a prescription is written, to get the information that that has happened. yes, the statute itself has that no patient should be compelled to participate, and it's not only physicians. if a pharmacist does not want to fill the medication, they do not have to. there's health systems. catholic hospitals, federal hospitals would not participate in there, they can decline to have a patient take the medications whilst on the ground. there's opt-out clauses. >> have there been any surprises along the way. people that changed their minds. people that embraced it. as oregon lived no the era, things this people didn't happen.

>> a couple of things, we don't ask specific things like this idea of people retracting medications. our job is to keep track of the data of who is participating, making it available. i have to say my perspective on that is that it's important. regardless of where you stand to see who has participated. it's true of atvo kates and people in opposition. >> the majority who participated have cancer. potentially after people exhausted treatment they may have a progress notion of less than 6 months to live. when we look at the education level. people who participate appear to be well educated, compared to

others dying of a similar age group, the average age is 70 years. some are holder, there's definitely younger. the well educated is something people were concerned about. that that may be disadvantaged. compelled to participate. >> as mentioned at the beginning, several states are looking for laws of their open. >> have any come to oregon. >> again, during the most recent period, i have certainly gotten phone calls from other states. the public health departments written in to their measures, their statutes, working through the legislature, and mostly acting about the reporting system. i work for the state of oregon, any materials introduced are public documents and other states can learn from that.

them. >> dr katrina headburn, the state health officer for the state of oregon, thank you for being was. we'll return for more of "inside story" after a short break. when we come back, we talk about the opposition. legal protections that have to be built into future laws, and the demographic tidal wave. tense of millions ending our lives at a time making it impossible to extend life, without asking sometimes if it's a life in a manner worth living.

welcome back to "inside story" on al jazeera america. i'm ray suarez. shortly after britney maynard's death a harris poll asked americans if they should be

allowed to end their lives in cases of terminal illness accompanied by great pain. sizeable majority favour physician issed suicide and euthanasia. 66% say doctors should be allowed to comply with the risks of patients in severe distress who ask to have their lives ended. up from 58%. opposition decreased from 20% in 2011 to 15% now. joining me for the rest of the programme, the director of the institute for human caring at providence health, and jessica, director of criminal affairs and advocacy for compassion and choices, supporting patients making end of life decisions. what happened to dying in america, that made ending your open life look like an

attractive proposition. >> in fact, it's hard to get good care through the end of life through people in america's health care system. we know that dying is harder than it needs to be. many people get treatments for their disease and get care through the last weeks and months. people are dying in ways they didn't want to sky. there is no debate. the institute of medicine reports documents that too many americans are dying with needless suffering. things that we could avoid and have solutions for. we have not done them in america. you are a physician, do you spend much time in med school in the standard med school course of study in american school, learning about the end of life? >> shockingly not. you know, again the institute of

medicine quoted a study from 2011 showing less than 17 hours of medical school curriculum was spent on end of life care. we don't teach hospice and palliative care. in oregon a member of family practice told me they are getting more required training in sports medicine than hospice and pat -- palliative. >> with everything you said, you still are a sceptic when it comes to death with dig in they why? >> i'm not a sceptic. i think it's troublesome socially erosive. if there are other options available to you, assisted suicide is just one choice. >> do you think that is the medical landscape that approaches people as they approach the end of their life? >> i think i agree with the

doctor, in that we need to work on comprehensive end of life care, making sure that people have all their options at end of life encompasses what end of lie means. compassionate choices is a consumer organization offering all choices. >> when people approach you, what are the situations they find themselves in. i mean, it's an important dig, and not one that people are bound to take lightly. but they must be pushed to you by desperation. >> i work on campaigns across the country, advocating for options and care at the end of life. volunteers and supporters come from all walks of life. they are there to make sure that dying people have rights and options available to them. and that we don't see cases - i'm from montreal, l and we want to -- and we want to make sure

we don't see cases where people use violence. and they can have an honest and frank conversation with their doctor to explore their options. in states like oregon, which started the death with dignity debate. they have people in hospices early. when people have frank conversations with their doctors, and the person is the consumer, working with the doctor, there's less violence at the end of life. >> as i was preparing for the programme, and reading people's stories about how they came to these decisions, one thing that jumped out at me was people's fear of being incapacitated closer to the end, and unable to communicate their wishes so they decided to end things earlier because they were so afraid of a timeline when they would want to check out and wouldn't be able to tell anyone. >> in states like oregon,

washington and montana, they can have the honest conversation, and get information about what the end of their life will look like. they can bring out the questions, and talk to a doctor and be able to - a third of the people who get the prescription never end up using the medication, they don't use it right away. there's people - there's a palliative effect to having options and choice. and when you have a disease with everything is taken away interest you. making the decisions on your own is important. >> isn't the idea of being so fearful that when you are really bad in really bad shape, no one will know, that they are willing to kill themselves now, is that an indictment of the system we have now on its face. >> i think the whole - all of our whole end of life system, and all of our end of life health care, and i am sure the

doctor will agree, needs to be consumer driven. that the individual is in control of end of life. they can say yes or no to treatment. they can, in certain states, they have that option. they have the option to have tests or not, because we'll see better end of lie care when consumers wake up and realise them. more "inside story" after another quick break. when we come back, questions about the current quality of end of lie care. is some of the call for patient choices about ending life a result of the way we manage pain in the chapters of terminal illness if we did a better job, would newer look for the relief that only comes with death. that is ahead on "inside story".

we're back with inside story on al jazeera america. i'm ray suarez, and i'm going to die. you're going to die. and for almost all of human history, there was little an individual could do outside ending his or her life to name the day. you can be taken by accident or illness or have your life taken by another person. death came quickly and unavoidably from diseases and illnesses plaguing the human body. today in america, there are untold american people who at another time would be dead and still face suffering that would make death a valid choice. most places in america insists it's not one they should make, we are continuing a look at death with dignity laws, with director of compassion and choices, and a professor of medicine is the the school of

medicine. doctor, one thing you here over and over is how bad we are at pain management. why is that? >> because we have not made a commitment in medicine schools or protocols of medical practice. an article in the an nuls of medicine, it shows that moderate to severe pain is rising. this is troublesome. we know how to care - i mean, we have the capacity to take care of people's symptoms, and the capacity to care for people in ways that allow them to feel comfortable. again, the best hospice and palliative care practices can do this, but we are not doing this. i want to agree with some of the premise of the polling that you

mentioned, saying that if people were in uncontrolled pain they would want the right to die. but, you know, in oregon, that's why this law was - or citizen initiative was passed by the electorate, because of uncontrolled pain. 25% of people who inguest drugs to die report pain as a rationale. a large majority, over 40%, it's a burden to the family. over 80% loss of the ability to do what they want or loss of autonomy or dignity. we can address that. on the other hand there's a lot of people who are not terminally ill, but feel the same emotions. people with alzhiemer's may feel hopeless, and yet, you know, right now the oregon law disallows them. don't they have rights? >> let me put that to jessica. are there licit and illicit

reasons that a person could have for wanting to die. are there people who present themselves if a state passes a death with dignity law, where someone would look at their reasons and say "no, let's treat you for depression, if you are hopeless, let's talk about that before giving you the means to end your life." >> a couple of things, from the american alliance of cancer pain initiatives, 5-10% of dying patients do not achieve substantial pain relief. 7.5 million people are not receiving that right now. i - with physicians, and when you are washing patients, when you decide hospice, and you allow them to stop treatment or a vent lator call, you are aware and judging from mental competency. doctors are checking that. i think all the evidence we have

seen in oregon and washington and montana is that there are mechanisms for doctors to check that. people are not running to use the medication. they are not - they are - they are checking. it gives them a sense of solace to have that. >> just a moment. there's mention that 40% reported not wanting to be a burden to the family is a reason for wanting to end their life. is that legitimate or addressable, or counselable so that killing yourself is not one of the menu its that faces you. >> i want to make it real clear. the people that we are talking about are not killing themselves. them. they are making a decision about when and where they want to die and what that looks like. the disease is what is killing them. that needs to be clear that

cancer is killing these patients and these people. >> they are choosing the day of their death by causing their death. i understand your point. but when someone is at the point where they are saying the reason i want to die is because i'm hopeless or don't want to be a burden to my family, are they willing to give them that autonomy, and a lot of people are against this. this is what they fear. an aversion of loose slots in vegas, as long as you feel bad enough we'll give you the wherewithal to end your life now, other than in the future. >> having death with dignity acts and an option, allows people to have the conversation, and they are not doing to covertly, privately, they have the family and doctor involved. they are not using violent means to end their life, they are having a conversation with their doctor.

it's out there, in the public discourse, not something lingering in the back of their mind, and they have to go into secrecy to achieve the ends they want. having a death with dignity makes sure that folks are having doctors. what do we have to do in the short term, doctor? >> many people talk to me about wanting to end their lives, and my role as a hospice and palliative physician. it's okay, we can have the conversations, we are not troting people's pain -- treating people's pain well, we are not teaching doctors to care for dying patients. our health care system makes paupers of well-to-do people for having diseases and not dying quickly enough. we send them to nursing homs, i

wish that among the proponents, we can redirect the dollars, ta change and establish nursing homes, and assure people of being wanted, worthy and dignified. that's the country i want to live in. i think we are better than this. it's expensive to write a lethal prescription to take good care of seriously ill people. let's raise the expectations and make the world one we want live in. jessica, doctor, i think you disagree on plenty, but one thing you agree on is making death a better experience for more americans. thank you for being with us, and thank you for joining us on "inside story". get in touch on facebook, follow us on twitter and watch us next too. in washington, i'm ray suarez.

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