The telephone call from the pharmacist came when Neil Mahoney could still stagger from his bed to the porch of his mobile home to let his boisterous labrador out.
Mahoney, a once-rugged outdoorsman, now reduced to gaunt bones and a swollen belly riddled with incurable cancer, sighed with relief when he went back inside and heard the message.
Your prescription is ready, it said.
The call came in late September last year, and after the 64-year-old had faced months of obstacles he finally had access to lethal drugs under Colorado’s 2016 End of Life Options Act. The state is one of a growing number in the US that allow terminally ill patients to obtain medications to end their own lives.
Even as an increasing number of US states have legalized assisted dying laws, exercising that option is challenging for patients in a country where many large hospital systems have deep religious ties. About one in six hospital patients are now cared for at a Catholic hospital, according to the Catholic Health Association.
Centura Health Corp, the Christian-run hospital where Mahoney sought treatment for his cancer, regards assisted dying as “intrinsically evil”, citing the firm’s governing rules, the Ethical and Religious Directives for Catholic Health Care Services. The hospital has barred its physicians from following the state law. In August, it fired his physician, Dr Barbara Morris, for consulting with Mahoney with the aim of carrying out his wishes.
The pair jointly sued the hospital for wrongful dismissal, though Mahoney had to drop out as his condition deteriorated. The case is still pending and she was unable to assist him.
In opposing the practice, the country’s religious institutions have received support from the Trump administration, which has consistently given providers wide latitude to refuse to participate in medical interventions they object to on religious grounds, though that has previously applied primarily to abortion and contraception.
When Centura fired Dr Morris for encouraging “a morally unacceptable option,” Mahoney lost both his doctor and the confidence that he would be able to end his life when the suffering became too great.
So the brief message on his phone meant an important victory. “This way I can say, ‘Yes, I can go,’” he said last summer. “I can call them up with a couple days’ notice and do it.”
Dozens of states consider assisted dying laws
Oregon has been in the vanguard of permitting assisted dying in the US, approving it more than two decades ago. In recent years, seven other states and Washington DC have followed suit.
It’s being considered in more than a dozen other states.
Internationally, providing medical assistance to end a life is legal in Belgium, Canada, Colombia, the Netherlands, Luxembourg and Switzerland. In the UK, there is a total ban on assisting terminally ill people from being helped to end their lives, though cases on the issue regularly come before the courts, and legislators have called for laws to be reviewed.
In the US, some doctors are barred from participating by their employers. Others refuse to do so. In some cases, the drugs themselves may be too expensive. A dose of Seconal, which is commonly prescribed, can be more than $3,000. The government and some private insurers won’t cover it.
One of nine siblings in a close Catholic family, Neil Mahoney seemed an unlikely candidate to test the Colorado law. He’d never previously had a major illness or injury despite years of physical labor.
In recent years, he managed planting crews at a wholesale nursery near Denver. “The dahlias have always been one of my favorites,” Mahoney said.
Mahoney was never comfortable around doctors, said his youngest brother, Patrick Mahoney, 60, who supported his older brother in his efforts to obtain help in planning his death. “Neil had a long belief that health systems, including physicians, capitalize on those that are ill,” Pat Mahoney said.
Neil Mahoney started feeling sick last January, but didn’t see a doctor. By mid-June, he couldn’t ignore a bout of stomach cramps, nausea and vomiting that sent him to urgent care.
In July, tests at a local cancer center confirmed the bad news: stage 4 adenocarcinoma, a cancer that forms in the body’s glands.
There’s no cure, the doctor said. Without treatment, Mahoney could expect to live four months. With chemotherapy, he might make it a little more than a year.
He immediately asked about medical aid-in-dying. He was among the 65% of Colorado voters who supported the law in 2016 and now expected to use it. The medical oncologist turned him down flat.
Neil Mahoney recalled: “I feel like I got slapped in the face.”
‘The healing ministry’
Mahoney’s primary care doctor had no qualms about participating. At 65, with 40 years of experience, Morris said that in her view, medical right to die should be part of a continuum of care for dying patients.
“We cannot know when a person has reached their limit of suffering,” she said. “Only that person knows.”
Centura, which is jointly run by Catholic and Seventh-day Adventist churches, describes its work as “the healing ministry of Christ”.
When it became aware of the plans in the works, Centura fired Morris, contending that Morris had violated an employment contract requiring her to abide by its faith-based rules. Morris immediately lost her malpractice insurance and access to a medical office, leaving her unable to prescribe drugs or provide care for Mahoney and her other patients.
The lawsuit she and Mahoney filed in August alleged that Centura’s faith-based policy violates both the End of Life Options Act and Colorado laws barring health systems from interfering with medical judgment. It sought to clarify whether Centura could prevent Morris from helping Mahoney as long as he wasn’t on the health system premises.
“We believe it is a morally unacceptable act, regardless of how you couch it, and we are not going to participate in it,” Centura’s chief executive, Peter Banko, told Kaiser Health News.
Mahoney didn’t have the time to let the legal battle play out in the courts. By July, he’d lost 30 pounds from his 185lb frame. He grew weaker, and his gut wrenched with pain from tumors at the junction of his stomach and esophagus.
The Mahoney children had watched their mother, Charlotte Mahoney, endure a slow decline two weeks before her death in 2007 at age 85. “I did not want to face an agonizing death without any means to help control when and where I will die,” Neil Mahoney told lawyers.
Forced to take a backdoor
With his own doctor’s hands tied, a desperate Mahoney had to resort to a backdoor route to exercise his legal right. Rodney Diffendaffer, a pharmacist, runs a network that quietly connects terminally ill patients in Colorado with doctors willing to follow the law. He reached out after reading about Mahoney’s dilemma.
“It’s his choice to have that drug,” said Diffendaffer, 51, who works at the independently owned Flatirons Family Pharmacy in Longmont. “No one else should even have a say.”
In the past two years, Diffendaffer’s fledgling group, Dying with Dignity of the Rockies, have helped more than 50 terminally ill Coloradans obtain medications to end their lives. “I have seen the pure torture that people went through,” said Diffendaffer, who grew up on a farm and says dying animals are treated more humanely.
Although nearly 4,000 people in the United States have used medical right to die law via their primary care doctors, groups like Diffendaffer’s, have emerged to match patients with doctors who are willing to help.
The opposition grows not just from powerful religious medical centers, but also the loud voice of the religious right in national politics as well as a genuine discomfort among some physicians who are loth to use their skills to end lives rather than to save them.
Dr Ira Byock, founder and chief medical officer at the Institute for Human Caring at Providence St Joseph Health in Gardena, California, has long opposed the practice he calls “hastened death”. He said his objections are based on his understanding of his profession, not on faith. “Ending somebody’s life intentionally is not part of medical practice,” he said. “It is something else.”
Neil Mahoney’s choice
Dr Glenda Weeman, a family physician who operates an independent practice in nearby Longmont, agreed to prescribe for Mahoney after he went to her office for an exam, which confirmed he met the law’s requirements.
Weeman, 60, had only prescribed right to die drugs for one patient before Mahoney under Colorado’s relatively new law. “My role is to relieve pain and suffering. That is my job,” Weeman said. “I have to help people understand that there are choices.”
By late September, Neil Mahoney had his prescription, which included two anti-nausea drugs and a cocktail of four medications that would induce death. He paid about $650 for it, out of pocket from insurance.
Still, he wasn’t sure if he’d use them. About a third of people who get the drugs don’t wind up taking them, data from Oregon and Washington show.
“It’s a little spooky,” Mahoney said on 30 September, sitting in his small, cluttered mobile home. He’d lost another 20lb. Around his neck was a pendant that said DNR: do not resuscitate.
Though more frail every day, Mahoney still had a list of things to do. A friend had promised to care for Ryder, the dog. The cat might do OK on her own, though his sister later offered to take her. He wanted to write a will. Two of his brothers took turns sleeping on his couch to offer assistance. “It’s quite a turnaround,” he said quietly. “Instead of planning for retirement, I’m planning for death.”
Neil Mahoney knew he had a window of time where he could take the medicine. If he waited too long, he wouldn’t be able to swallow it.
On Tuesday, 5 November, he decided it was time.
At 9.45pm, in bed, surrounded by family, Neil Mahoney took the drugs to halt anxiety and nausea. Minutes later, using a straw, he quickly drank the rest of the medications.
About 10.45pm, his brother Pat “felt for his pulse. I put my hand on his chest to check his respiration rate and then I said ‘He’s gone’.”
Reached by email, Barbara Morris was somber about the death of a patient that the religious teachings of her former employer had prevented her from helping. She’s found another place to practice, starting in the new year. “It was a great honor to know Neil both as his doctor and his friend,” she wrote. “Out of respect for his memory, we will continue to advocate for care focused on patient values and wishes.”
• This article is co-published with Kaiser Health News, which has ongoing coverage of issues around assisted dying.