Because the law took effect 90 days after the Legislature adjourned, its special session pushed the start date into summer. “The California law will permit physicians to provide lethal prescriptions to mentally competent adults who have been diagnosed with a terminal illness and face the expectation that they will die within six months,” as the Los Angeles Times reported.

After maintaining a long holding pattern, the patchwork of stakeholders involved in the change have shifted into action. “As the implementation date nears, medical groups, supporters, legislators and others are working to raise awareness of the new right-to-die law and ensure all terminally ill patients will have access to it,” CNN reported. “They are holding webinars, panels and town hall meetings, distributing information and setting up telephone lines.”

Substantial hurdles

Resistance to physician-assisted suicide has remained strong since legislation was first proposed, however. Combined with the relatively narrow tailoring of the law, crafted to achieve passage in Sacramento and adequate support statewide, “it still is unclear how the law will play out in California,” as Ben Rich, a bioethics professor emeritus at the UC Davis School of Medicine, told CNN. “He said he expects some health institutions to be supportive and others to be unsupportive, leading to inconsistency around the state,” the network noted.

As it stands, Californians trying to avail themselves of the new process will have a laborious road ahead. “In January the state published guidelines for how the lethal drugs can be prescribed and administered, establishing a lengthy process to ensure that patients are making informed decisions,” New York Magazine observed. “Any patient wishing to be prescribed lethal dosages have to make two verbal requests, 15 days apart, and one written request. He or she has to be at least 18 years old, and a physician has to rule out mental illness.”

A limited trend

Even with its hurdles, the change has been hailed as yet another of California’s supposed bellwether bills. But states that have followed California’s lead on other issues may not be ready this time. In Maryland, this month, similar legislation went down to defeat, following a broader pattern. “Maryland is one of 25 states, along with the District, that have introduced what advocates call ‘aid-in-dying’ legislation since the highly publicized suicide of Brittany Maynard, a 29-year-old California woman who had terminal brain cancer and moved to Oregon in 2014 to legally end her life,” the Washington Post observed.

Kim Callinan, of assisted suicide group Compassion & Choices, told the Post it often “takes multiple times,” to make legislative headway. “In addition to California and Oregon, aid in dying is permitted, with varying restrictions, in Washington state, Vermont and Montana,” as the paper added.

Much comes down to the personal predilections of each state’s governor. Jerry Brown was seen to grapple with the philosophical precepts at stake in legalizing assisted suicide. “In the end, I was left to reflect on what I would want in the face of my own death,” he revealed in his signing statement, as the Los Angeles Times relayed. “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.” Despite broad American trends toward a more individualistic view of the meaning of life, few governors, even in states where evangelical Christianity and Catholicism have not often mobilized to sink legislation, share Gov. Brown’s unusually spiritual — but distinctively Californian — outlook.

The move capped a long and sometimes tortuous effort to get legislation through the state Legislature, where opponents of elective death managed to mount a successfully targeted opposition that was eventually overcome.

Initially, the bill’s progress was smoothed when the California Medical Association ceased its opposition, as the Huffington Post noted, leading state Senators to pass it this June. “But before it could be brought to a vote in the Assembly, lawmakers abandoned the bill in committee amid opposition from the Catholic church as well as disability rights advocacy groups.” That led supporters to rejigger the legislation in special session last month, “adding a sunset provision so that the bill will expire in 10 years unless legislators vote to extend it. The bill passed in committee by a 10-2 vote before going on to the full legislative body for consideration.”

Murky ethics

Brown’s logic for accepting the bill, conveyed in an unusually personal signing statement, hinted at the murky ethical territory into which the assisted-suicide movement has plunged officials in multiple states. While advocates characteristically consider at least some terminally ill patients to possess a human right to end their own lives, Brown seemed intent on sidestepping that question in favor of a more agnostic view.

“In the end, I was left to reflect on what I would want in the face of my own death,” he wrote, CNN noted. “I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill.”

As ABC News reported, Brown “said he consulted a Catholic bishop, two of his own doctors and friends ‘who take varied, contradictory and nuanced positions.'” Traditionally, elective suicide has been seen as a moral problem for patients as well as doctors, famously sworn to “first, do no harm.”

But that once-sturdy consensus has begun to collapse, perhaps especially in socially libertarian states like California. “Roughly two-thirds of U.S. adults (68 percent) say doctors should be allowed by law to assist patients who are terminally ill and living in severe pain to commit suicide,” Pew observed. “That’s an increase of 10 percentage points in just one year, and 17 points over two years.” Meanwhile, “a new Field Poll released Monday found two-thirds of California registered voters supported a proposal to give patients the right to obtain life-ending drugs, with support cutting across most religious and political party lines,” according to the San Jose Mercury News.

Legal wrangling

Yet California’s version of legalized assisted suicide did not reach as broadly as the majority public opinion may wish. “The new law requires two doctors to determine that a patient has six months or less to live before the lethal drugs can be prescribed. Patients also must be physically able to swallow the medication themselves and must have the mental capacity to make medical decisions,” NPR noted. “One of the meetings must be private, with only the patient and the physician present. […] Patients must also reaffirm in writing that they intend to take the medication within 48 hours.”

Opponents have warned that those safeguards aren’t enough to prevent abuse. “Tim Rosales, spokesman for the Californians Against Assisted Suicide Coalition, said opponents of the law aren’t giving up their fight,” the Mercury News reported. “They vowed Monday to explore their options, including a referendum or legal action to repeal the law.”

Rosales and his allies were bolstered by the trouble assisted suicide has encountered in the courts. “It was permitted in New Mexico until August, when an appeals court in the state reversed a lower court ruling that had established physician-assisted suicide as a right,” NPR added. “The New Mexico Supreme Court is now hearing that case.”

After the Assembly greenlit the legislation 44-35, the state Senate cleared it with a 23-14 vote, CNN noted, bringing to a climax a controversy begun almost a year after the death of terminal brain cancer sufferer Brittany Maynard moved from California to Oregon in order to legally end her life before succumbing to the disease.

With passions running high on both sides, “Brown has not indicated where he stands on the issue, nor whether he will sign or veto the bill,” KQED reported. “If he does nothing, after 30 days the bill will become law.”

“If Gov. Jerry Brown signs the bill, California would become the fifth state to allow doctors to prescribe lethal medication to terminally ill patients who request it, after Oregon, Washington, Vermont and Montana.”

That, according to the New York Times, would triple the number of Americans who could successfully opt to go through with an assisted suicide. As is now routine with controversial California bills, supporters and opponents alike have suggested that Brown’s signature would set off a chain reaction of similar legislation around the country. Already, the Times added, over half the nation’s states “have put forward bills this year to legalize some kind of assisted suicide, according to the Death With Dignity National Center,” although as yet not one bill has made its way into law.

A second try

The bill, known by the special designation ABX2-15, followed in the wake of an effort that fell victim to objections focused on key members of the Assembly Committee on Health. Much like that bill, ABX2-15, introduced by Assemblywoman Susan Eggman, D-Stockton, “would allow some dying patients to end their lives through lethal doses of medication, as long as medication is self-administered; the patient is mentally competent; and two physicians confirm the prognosis that the patient has six months or less to live,” as California Healthline observed.

“Several amendments were added to the bill in the special session, including one that would require patients to reaffirm their consent within 48 hours prior to taking the lethal dose of medication. The bill’s authors also added an amendment that would sunset the law after a decade, making it effective only until Jan. 1, 2026, if passed. However, the state Legislature could vote to extend it.”

Reading the tea leaves

Observers looking for clues on Brown’s disposition noted that he has shown some dissatisfaction with the circumstances under which the legislation was advanced. As the Washington Times noted, “he has taken issue with moving the bill during the current special session, which is supposed to be focused on health care financing instead of the regular session.” Outside critics echoed Brown’s concern. “Californians Against Assisted Suicide spokesperson Tim Rosales said the bill was being rushed through the Legislature’s special session,” CNN reported.

Those opposed to the bill have placed their faith in Brown’s personal religious history. “Everybody’s interested because Jerry Brown’s a Catholic,” political analyst Allan Hoffenblum told the Times, referencing Brown’s well-known time in seminary.

Ongoing litigation

The development did not slow activists’ push for immediate change. In San Diego, the Fourth District Court of Appeal heard plaintiff Christy O’Donnell’s claim that the state should allow her to seek assistance in ending her life in advance of her death from lung cancer that has spread throughout her body. Through Attorney General Kamala Harris’s lawyers, the state countered that “long-standing California law in matters related to terminal illness” should not be swept aside, as the San Francisco Chronicle reported. Harris’s office further argued that O’Donnell’s request for accelerated review also be denied, according to the Chronicle, with the usual appellate process sometimes taking more than a year.

A reticent judge

“San Diego Superior Court Judge Gregory Pollack said his court is not unsympathetic to their plight but lawmakers — not a judge — would need to change the law barring such prescriptions,” according to the Associated Press. “Pollack said in his written ruling that the current law that makes it a felony to assist a suicide in any way is constitutional and so he does not have the power to suspend its enforcement.”

The plaintiffs in the case, expected to appeal, became the latest terminally ill patients to rise to prominence as Californians grapple with the propriety of induced death. “Christy O’Donnell, 47, a cancer patient and the lead plaintiff in the case, had sought to obtain the legal right to end her life because, in part, many common painkillers, including morphine, have not worked for her,” the International Business Times reported. “Another plaintiff, Elizabeth Wallner, 51, was afflicted with Stage IV colon cancer that has metastasized and reached her liver and her lungs.” Pollack insisted “new law” must be made “by the Legislature or by a ballot measure.”

Wallner, for her part, conveyed her steady determination to keep the case going. “This is certainly frustrating, but it’s a temporary setback,” she said, according to KQED. “I am optimistic that we’ll prevail in the end. It’s too big of an issue to leave uncovered.”

No legislation

The frustration of Pollack, O’Donnell and sympathetic activists has been fueled by a successful effort to sink a bill in Sacramento that would have wiped out the state’s ban through the legislative process. As the AP reported, earlier this month, Senate Bill 128 — modeled after neighboring Oregon’s law — cleared the state Senate but ran aground in the Assembly Health Committee, “a panel that includes multiple Democratic lawmakers from heavily Catholic districts in the Los Angeles area, where the archdiocese actively opposed the legislation.”

Los Angeles Archbishop José Gomez targeted fellow Latino Catholics Jimmy Gomez, D-Los Angeles, Roger Hernandez, D-West Covina, and Freddie Rodriguez, D-Chino, urging in a strongly worded letter that SB128 be rejected. After the assemblymen turned against the bill, cosponsors Sens. Lois Wolk, D-Davis, and Bill Monning, D-Monterey, had to pull it — leaving observers to wonder whether it might be introduced in altered form at a later date.

The ordeal counted as something of a win for Gov. Jerry Brown, who had not indicated whether he would sign a right-to-die bill, and likely wished to avoid the divisive controversy either way.

A broader trend

For activists nationwide, what had seemed like a possible tipping point in California has led to disappointments around the country. “Some advocates say they thought the nationally publicized case of Brittany Maynard, the 29-year-old California woman with brain cancer who moved to Oregon to legally end her life last fall, might usher in a wave of state laws allowing doctors to prescribe life-ending medications,” the New York Times noted, “but that hasn’t happened.”

Critics of legalizing the practice have viewed the shift from a legislative to a judicial strategy as evidence that the push for change has almost run its course. “Tim Rosales, a spokesman for California Coalition Against Assisted Suicide, said the lawsuits show right-to-die advocates are getting desperate after the setbacks,” according to the Times.

Nevertheless, the issue showed little sign of fading completely into the political background. Montana, New Mexico, Oregon, Vermont and Washington have all passed laws permitting assisted suicide, and 70 percent of Californians voiced their approval for a similar approach in a poll conducted at the beginning of the year.

Maynard, 29, an assisted-suicide activist living in Oregon, advertised her impending death as a dignified response to the “aggressive” form of terminal brain cancer that left her with a few painful months of natural life. Maynard moved from the San Francisco Bay Area to Oregon to avail herself of the state’s 1997 law authorizing a narrowly tailored right to die at the hands of doctors.

Now legislators in Sacramento have borrowed the language of that law to draft a version that would protect assisted suicide throughout California.

Careful wording

Despite the vogue for so-called “death with dignity” bills, which are now in the works in 14 states nationwide, opposition to legal suicide is strong enough that California legislators opted to stick with the narrow terms laid down in the Oregon statute.

The bill, SB128, stipulates a long list of conditions that must be met for a person’s request to terminate their life to be fulfilled. For instance, only mentally competent adults given six months or less to live, and equipped with an in-state driver’s license and voter registration, may make the request of their attending physician.

The numerous legal hurdles are part of an effort to ensure the bill is not successfully portrayed as greasing a slippery slope toward fuller suicide rights. In 1992, California voters sank the Aid-In-Dying Act, reversing an apparent trend of support for the measure.

And as U-T San Diego reported, similar bills “were defeated last year in New Hampshire, Connecticut and Massachusetts by a coalition of disability rights groups, medical associations, hospital workers and right-to-life groups.”

Those groups included the Catholic Church, which was instrumental in preventing assisted suicide in California and is expected, like other organizations, to mobilize against the current wave of bills.

Critics also point out the experience in the Netherlands, which had 6,000 cases in 2014 out of a population of 17 million, is that limits on euthanasia can be expanded. London’s Daily Mail quoted Dr. Peter Saunders, “What we are seeing in the Netherlands is ‘incremental extension,’ the steady intentional escalation of numbers with a gradual widening of the categories of patients to be included.”

Political posturing

The delicate wording of SB128 nevertheless struck a clear contrast with the political imagery and posturing surrounding the bill’s introduction. Maynard’s husband and mother made the case for the bill at an uncharacteristically raw news conference where nine California legislators announced the legislation.

“She recognized that to stay in California would mean she potentially would face a horrific death,” her husband, Dan Diaz, told reporters. “Brittany was a Californian. We lived in this state and she would have preferred to pass away peacefully in this state.”

State Sen. Lois Wolk, D-Davis, who co-sponsored the bill with state Sen. Bill Monning, D-Carmel, echoed Diaz. “The fact that Brittany Maynard was a Californian suffering from an incurable, irreversible illness who then had to leave the state to ease her suffering was simply appalling, simply unacceptable,” she said.

Likely complications

Although Wolk, Monning and their allies have successfully capitalized on Maynard’s plans to make assisted suicide a fresh issue, they face opposition from political figures who can make or break SB128. Although in 1976, Gov. Jerry Brown approved a legal right for terminally ill patients to end so-called life-sustaining treatment, it’s unclear whether he’s willing to go as far as Wolk and Monning wish. He has yet to make public comment on the matter.

What’s more, SB128 faces big hurdles even before it can land on Brown’s desk. As Time reported, “Wolk expects the bill will make it out of committee and reach the Senate floor, but will have a tough time passing both houses of the Legislature.”

She told the magazine she expects a “heavy lift” in trying to secure passage over the objections of tradition-minded Democrats as well as Republicans.

As critics in the medical profession have observed, legally protected rights to suicide bring legal duties. In Oregon, for instance, the state-sponsored medical plan offered to cover suicide-inducing drugs instead of more costly cancer treatments.