In part one of this two-part blog, each co-author Professor Cerminara and Dr. Petrucci share a different perspective on the topic: one co-author shares her personal experiences, and one co-author shares a legal perspective. In part two, they explore additional legal examples.
The idea of peace-of-mind laws and therapeutic jurisprudence came up after a post on the TJ listserv*. A very sad story was shared in which a man with terminal illness committed suicide by shooting himself in his backyard. He lived in a state in the U.S. that did not have an aid-in-dying law. This story began our discussion of the role of laws that permit medical aid in dying (previously termed physician-assisted suicide or physician aid in dying) and the therapeutic peace of mind this type of law could provide.
Peace-of-mind laws could encompass laws whose presence brings a long-term therapeutic effect on quality of life for those impacted by them, while their absence elicits a negative impact. Notable aspects of this concept are that the impact, positive or negative, lasts years or decades, and there is a clearly felt negative impact on quality of life.
We’ll give two examples that have impacted the life of one of the co-authors: aid-in-dying laws for those who are terminally ill and access to health care brought about by the Affordable Care Act (ACA) in the U.S.
Aid-in-dying laws such as those enacted in California or Oregon lay out a clear and accessible procedure for people who are terminally ill to be in control of their end-of-life; this personal control contributes to peace of mind. Numerous jurisdictions across the world have recognized this benefit from aid-in-dying laws and, accordingly, have legalized the practice. In the United States, ten jurisdictions (nine states plus the District of Columbia) have statutorily implemented the option for people who are terminally ill, while one state, Montana, has authorized the practice through a ruling of its state supreme court (Compassion & Choices 2021). A number of countries across the world have authorized the practice as well, ranging from the Netherlands, where it is well-established, to Switzerland, Canada, and Colombia more recently. The state of Victoria within Australia has authorized a plan for aid-in-dying as well.
Admittedly, not everyone is concerned with end-of-life, but for those who are, it can be an everyday concern for a long period of time, even without the presence of illness. For example, one of us has a healthy octogenarian family member who, despite his libertarian philosophy of “less government is better,” expressed relief that aid-in-dying laws were at least available should he need them. He shared his preoccupation with worrying about the possible scenarios should he become ill or infirmed as he aged. Much to this co-author’s surprise, his knowing that their state had a legal aid-in-dying law put his mind at ease. It also allowed him to have the conversation with other family members about his wishes regarding his end-of-life. Having his wishes out in the open also likely brought some relief. Being elderly brings with it many quality of life concerns centered around the potential loss of one’s physical or mental abilities. End-of-life concerns can loom large among these. Even though not planning to invoke the law, this co-author’s family member derived comfort from its existence. While not every elderly person in their eighties or nineties has these concerns, for those who do and for other like-minded terminally ill individuals, the therapeutic benefit of a legally accessible aid-in-dying law could provide a significant amount of relief.
The second example we’ll share is access to healthcare for people with chronic health issues. For one co-author, insistence on having healthcare was fueled by an experience almost forty years ago in which a family member went through two years of cancer to her eventual death, all without medical insurance. Fast forward fifteen years, still prior to ACA, and now the same co-author has a family member with chronic illness that brought with it constant concern about getting healthcare (no easy task with a pre-existing condition), having enough healthcare (will this procedure or medication be covered?), reaching the “cap” or total amount that the insurance company would pay and losing health care permanently, and what seemed like a very real possibility of incurring significant debt or bankruptcy with the cost of hospital stays that averaged once per year. Access to health care dictated where they lived (in a metropolitan area close to large hospitals with the right type of care) and inhibited their ability to move out-of-state for job opportunities (and risk losing the long fought for state-run high-risk-pool healthcare coverage status, available for only a small number of those with pre-existing conditions). Health care also dictated their finances with premiums that constituted well over a third of their income. The passage of the ACA brought incredible relief with immediately lower coverage costs and the thought that health care premiums may be affordable in the future. It also brought relief that this co-author and her family would have their health care regardless of pre-existing conditions or reaching a cap. It brought relief that they could move anywhere in the country and still have access to healthcare. The quality of the health care coverage also brought relief, with the ten essential benefits for which the ACA required coverage. It was a gamechanger for the family, and probably for many others like them. The ACA has reduced this co-author’s day-to-day stress and anxiety about access to care, finances, where the family lives, and where family members work. In short, its presence has greatly improved this co-author’s quality of life.
Internationally, that concern may seem incredible. In contrast to most other countries across the world, the ACA was required to provide that ease of mind for citizens of the United States because of the lack of universal healthcare coverage in our country. While not implementing universal health care, the ACA attempted to come close to doing so within the confines of the United States’ distinct “non-system” for healthcare. In our “non-system,” healthcare coverage through insurance or other sources is a necessary but not sufficient pre-condition to receiving medical treatment in all but emergency situations. Most other developed countries in the world, of course, have universal healthcare (Commonwealth Fund 2020). It would be an interesting research project to compare peace of mind with regard to being able to satisfy healthcare needs among citizens of the United States and countries with universal healthcare. The annually published World Happiness Report hints at this possible relationship; these reports track quality of life across 150 countries and shed light on the complex ways this can be examined (SDSN, 2021).
No doubt there are many other examples of peace-of-mind laws and their therapeutic effects. The potential is huge, and we encourage others to consider peace of mind in their own legal analyses and research.
The suggested definition of a peace-of-mind law as described here is that:
(a) its absence creates constant worry and concern
(b) over the long-term
(c) for the quality of life
(d) of defined groups of people.
The presence of the peace-of-mind law:
(a) reduces stress and
(b) improves quality of life
(c) which brings about peace of mind.
You are invited to revise or add to this definition. Healthcare and end-of-life are two possible examples but there are numerous others that can span the political spectrum.
Peace-of-mind laws may be relevant based on one’s socio-economic status, age, gender identity, sexual orientation, or race-ethnicity. Whenever the therapeutic or anti-therapeutic consequences of our laws impact us on a daily basis, the peace-of-mind implications may be worth considering to improve the therapeutic consequences of law..
Kathy Cerminara, JD, LLM, JSD
Professor Cerminara began her academic career at the University of Miami School of Law, where she worked with the late Bruce Winick. Since that time, she has written about therapeutic jurisprudence, co-organized a number of therapeutic jurisprudence streams at the annual Congress of the International Academy of Mental Health, and served on the board of the International Society of Therapeutic Jurisprudence.
Carrie Petrucci, MSW, Ph.D.
Dr. Petrucci has been doing evaluation research for the last 20 years, specializing in criminal justice and social welfare programs. She has also conducted research and published several chapters on therapeutic jurisprudence.
TJ Listserv (April 8th,2021). Getting a Prescription to Die in the U.S. Remains Tricky Even as Aid-in-Dying Bills Gain Momentum. Therapeutic Jurisprudence Listserv, April 8th, 2021. https://groups.google.com/g/tjlist/c/UiW_iddriL4. * TJ listserv — The International Society maintains a useful TJ listserv with an international membership that may be joined by sending a BLANK email to TJlistemail@example.com
Compassion & Choices (2021). Understanding Medical Aid in Dying. Compassion and Choices Website. Viewed May 1, 2021. https://compassionandchoices.org/end-of-life-planning/learn/understanding-medical-aid-dying/.
The Commonwealth Fund (2020). International Health Care System Profiles. The Commonwealth Fund Website. Viewed May 1, 2021. https://www.commonwealthfund.org/international-health-policy-center/system-profiles. United Nations Sustainable Development Solutions Network (SDSN). World Happiness Report Website. Viewed May 20th, 2021. https://worldhappiness.report/archive/.