Auwe ua hala aku nei, O ka Lani iolani ka Moi

When the Vale of Death Appears: Death With Dignity in Hawaii

By Bill Kirtley

Central Texas College

NOTE: I retired after teaching high school for thirty years and followed my dream. In 1997, I earned a Doctor of Arts in Political Science at Idaho State University. Currently, I teach college level social science courses aboard deployed US Navy ships for Central Texas College and Columbia College.

My wife and I heard Scott Foster from the Hawai`i Death with Dignity Society speak at the Fifth Anniversary Forum on Oregon’s Death With Dignity Act in October 2002 in Portland, Oregon. In the spirit of Aloha he invited me to do research in Hawaii. The National Social Studies Association Journal published, Auwe ua hala aku nei, O ka Lani iolani ka Moi, When the Vale of Death Appears: Death With Dignity in Hawaii the following year.

I have followed developments in Hawaii since then. Dr. Lenora Lee pointed out in her well-written dissertation, A Good Death: The Politics of Physician Assisted Suicide in Hawaii, that there is an alternate spelling for the Hawaiian chant that I used in the title. I was even more amazed at how close Hawaii came to adopting Death With Dignity when I rewrote the paper for inclusion in my book. I noted that Governor Cayetano actually stood by, ready to sign the bill in the event that it passed the Hawaii Senate.

The editors of Athena Press of London indicate that my book, The Politics of Death: Oregon’s Death With Dignity Act will be available early in 2011. I look forward to many more visits to Hawaii talking story and observing the fight for Death With Dignity.

Sincerely, Dr. Bill Kirtley

September 8, 2010

I. Introduction

This paper’s title comes from a native Hawaiian chant composed at the death of King Kameamea (1834-1865).¹ It celebrates the resolution of all conflicts and the King’s reunion with his extended family as he enters the valley of death. Traditional beliefs hold that ancient Hawaiians could choose the time of their death and simply will themselves to die. Their phrase for it was, “Na kanaka-oku’u wale aku no i kau uhane” (The people dismissed freely their souls and died). There is evidence that many Hawaiians died in this traditional way. Dr. Benjamin Young, a psychiatrist at the University of Hawaii, commented, “If a person could control his destiny at such a critical stage in life, that would be beautiful.”²

Researchers are finding that death isn’t as much about pain as about controlling one’s destiny. This is what Yasim Anwar, a modern day resident of Hawaii, wanted for his father, Makhudum. In a letter to the editor of the Honolulu Advertiser, Yasim described how this family made decisions about the care of their moribund father who suffered from dementia, diabetes, and pneumonia. They came to a point where their father could no longer tolerate a feeding tube. Not knowing what to do, they asked one another what their brilliant, irascible father would say, if he were able. They concluded he would have told them, “Bloody hell, let me go in peace.”³ And so they did, but wished that their father while of sound mind had the choice of deciding when and how he died. The ongoing philosophical and ethical argument between proponents and opponents of the Hawaii Death With Dignity Act revolves around the question of whether the individual or society has primary responsibility for making this choice. This question will increasingly be asked of voters, state legislators, and judges as America’s society ages.

A. Appropriation of Terms

Death brings peace to the dying, but trouble for the living. The parties in conflict cannot agree on the terms defining the issue. Proponents call laws similar to the one in Oregon that allows competent terminally ill patients to request a legal lethal prescription from their physician, Death With Dignity. Opponents reply that words like dignity disguise a grim reality. They insist the only term that accurately describes what happens is physician-assisted suicide (PAS). I use the language of the participants on the context of their arguments, but refer to the term Death With Dignity because it is centered on a specific piece of legislation.

I have my own personal biases on Death With Dignity, or physician-assisted suicide, depending on which group is using the term. First, I believe that I can objectively evaluate the tactics of both sides as to their effectiveness. Second, when asked my beliefs on the subject while conducting interviews for this paper, I responded that my thoughts are conflicted, a condition that helps me empathize with both sides. My faith informs me of the value of life. My conscience tells me that it would be morally wrong to hasten my own death. However, I also believe that a merciful God does not need or want us to suffer and were I terminally ill and in pain, I might set these scruples aside. Moreover, being of a liberal bent, I hold that individuals, rather than the state, have the right to decide intimate personal matters and decline to pass judgment on others who do not share my values. In this paper, I seek to achieve a measure of objectivity by applying theory to practice and conclude with a discussion of the applicability of the theory, the realignment of political parties, and the future of end-of-life issues in Hawaii. First, let me set the stage by describing the diverse attitudes of the people of Hawaii about death and dying.

B. Death in Paradise

Hawaii is known for its multiethnic and tolerant society. According to the 2000 Census, the population of the state was 1,211,537 and the County of Hawaii was the most diverse county in the United States.⁴ The 2000 census shows that 24 percent of the residents of Hawaii are white, 16.7 percent are Japanese, 14.1 percent Filipino, and 9.4 percent Native Hawaiian. These figures only hint at the complex amalgam of cultures in a state where 45 different languages are spoken and 21 percent of the people claim mixed heritage.⁵

People in Hawaii’s multicultural society view death in different ways. Japanese-American attitudes on dying reflect Christian, Buddhist, and Shinto traditions. Professor Kathryn L. Braun, DrPH, Director of the University of Hawaii Center of Aging, reported that Hawaii’s 1998 state behavioral risk and assessment system, a random-sample survey, indicated that of Japanese-American respondents, 75 percent have completed advance directives and 70 percent support physician-assisted suicide (PAS) and physician-assisted death (PAD) by voluntary lethal injection.⁶ People of Chinese ancestry living in Hawaii demonstrated similar attitudes, with the exception of dying at home. Of Chinese respondents, 43 percent wished to die at home compared to 76 percent of the Caucasian respondents. Braun reported that many people of Chinese ancestry did not want to answer end-of-life questions because they felt it was bad luck to talk about death. Caucasians embrace a variety of religious beliefs, but generally believe in the values of autonomy and self-determination; 70 percent favored PAS and 65 percent favored PAD.⁷ Native Hawaiians are the least likely to have an advance directive (22%); 55 percent favored PAS and PAD, perhaps as a result of their generally disadvantaged economic status. Filipino’s indicated the lowest support for PAS (45%) and PAD (44%), a reflection of their culturally shaped attitudes toward death.⁸ Other surveys confirmed Braun’s hypotheses that end-of-life preferences vary among ethnic groups.⁹

C. Coalitions in Conflict

Eleven Hawaii medical, hospice, and religious groups formed Hawaii’s Partnership for Appropriate and Compassionate Care (HPACC) in 1999 to oppose the recommendations of the Governor’s Committee on Death and Dying for the legalization of PAS and PAD.¹⁰ The members of this coalition formed a true partnership that relies on the unique skills of its individual members. Kelly M. Rosati, Executive Director of Hawaii Family Forum, who was selected as one of Hawaii’s most influential women, served as coalition spokesperson, aided by the impassioned arguments of Kenneth Zeri, President of Hospice Hawaii, and the political know-how of Deacon Walter Yoshimitsu, manager of diocesan services for the Roman Catholic Diocese of Hawaii. Yoshimitsu and Zeri agreed that the secret of their coalition’s success was sticking to one issue.¹¹ Heidi Singh, director of legislative and governmental affairs for the Hawaii Medical Association, put it this way, even though HPACC represented a “broad range of voices, everyone is singing off the same song sheet.”¹² HPACC’s leaders asked that they be interviewed as a group, a sign of their cohesiveness.

Proponents of right-to-die legislation formed Hawaii Death With Dignity (DWDH), a coalition of eleven organizations to support a bill in the 2002 session of the state legislature similar to the law passed by the voters of Oregon.¹³ Scott Foster, a public relations and marketing expert, served as communications director of the group. Foster, an advocate of gay and lesbian rights, helped pass the nation’s first medical marijuana law in Hawaii and served as Governor Cayetano’s campaign communications director. Andi van der Voort, President of the Hemlock Society, furnished funds and assistance, but elected to stay in the background. Although the legal status of assisting someone to commit suicide is unclear in Hawaii, the Hemlock Society’s commitment to help people use non-medical means to die is clearly inflammatory.¹⁴ Roland Halpern, a long time supporter of Death With Dignity, added solid leadership and administrative skills to the coalition after his appointment as Executive Director of Compassion in Dying of Hawaii in May 2002.

II. Theory

Interest groups, unlike political parties, do not strive to gain power for themselves; they influence government through lobbying and educate the public on a narrow range of issues. Interest groups differentiate their appeal in an effort to attract potential members by focusing on specific ideas and issues. For example, Compassion in Dying Hawaii focuses on medical means of hastening death. Although the Hawaii Hemlock Society supports passage of the Hawaii Death With Dignity Act, the group is primarily geared to educating their members on non-medical means of dying without the help of a physician. Despite these built-in differences, members of interest groups often belong to several similar groups, thus facilitating the building of coalitions. Three areas of theory provide tools for the analysis of the conflict between two coalitions, DWDH and HPACC: first, the pluralist theory, second, anti-pluralist critiques, and third, Maurice Duverger’s hypotheses.

A. Pluralism

In The Federalist Papers, No. 10, James Madison wrote that “liberty is to faction as air is to fire.”¹⁵ Faction was Madison’s term for interest groups. He argued that limiting them would limit liberty itself. He believed that no single faction would dominate if interest groups were left to compete among themselves in a sufficiently large country where power was distributed throughout the branches and levels of a federal system of government. In this situation, the natural competition of factions would limit their power. David Truman and Robert Dahl argued that the Madisonian position in modern terms means that the competition of interest groups will eventually result in compromise, moderation, and what was best for the country.

I believe that events in Hawaii confirm the pluralist position; end-of-life care in Hawaii improved as a result of the conflict between coalitions. The debate intensified after Governor Benjamin J. Cayetano (D) became interest in death and dying issues after his 85-year-old father, Bonifacio, died a “not so dignified” death.¹⁶ He convened an 18-member committee on death and dying in 1996 headed by Hideto Kono, a highly respected elder statesman. The committee agreed unanimously on its first six recommendations, but split by an 11-7 vote in favor of the seventh and eighth recommendations. The recommendations of the Governor’s commission are as follows:

1.Spiritual counseling be made more available to the dying.

2.Education be implemented to increase awareness of choices available to the dying.

3.The use of advance directives be made more specific, bindings, and widespread.

4.Hospice care be made more available.

5.Mandatory pain management programs in all health care institutions

6.Involuntary euthanasia should continue to be a crime.

7.Legalization of physician-assisted suicide (Physician provides the lethal agent by which the patient ends his or her life.)¹⁷

8.Legalization of physician-assisted death (Physician administers a lethal agent with the intent to cause the death of a patient.)

The committee justified their vote on the last two recommendations by declaring that “Our respect for individual’s rights of self-determination brings us to the view that request for assistance in dying should be taken seriously,” a sentiment that galvanized those morally and ethically opposed to PAS and PAD.¹⁸

B. Pluralist Critique

The beneficial results of end-of-life discussions in Hawaii demonstrate the validity of pluralism, and because of that, I agree with political scientist Jeff Berry, author of The Interest Group Society, that pluralism “should not simply be discarded like a rejected hypothesis in a small research project.”¹⁹ Whatever the deficiencies of pluralism, it still serves as a goal. At the same time, I concur with those who have pointed out deficiencies of pluralism centering around the elitism and resistance to change exhibited by interest groups. Floyd Hunter in his study of Atlanta, Georgia, Community Power Structure, charged that interest groups control communities through “fear, pessimism, and silence.”²⁰ Leaders of entrenched groups fear change and ordinary citizens, lacking the means of self-expression, cannot voice their opinions. Theodore Lowi, in his work The End of Liberalism, argues that long-standing relationships between interest groups and government agencies weaken popular control, maintain privilege, and resist change.²¹

Members and the leadership of interest groups are drawn from the elite. Scott Foster, communications director for DWDH, has a lifetime of political experience. The supporters of Compassion in Dying Hawaii tend to be politically minded professionals and its clients terminally ill Caucasians, “better off financially than most.”²² The Hemlock Society targets a similar clientele, but its more radical approach appeals to those who have lost faith with the existing legal and medical systems. Hawaii voter registrations, until recently, included the age of voters. Andi van der Voort, president of the Hemlock Society of Hawaii, used this information to send recruiting letters to the elderly in which she laments the “bullying tactics” of a “small group of well-financed anti-choice zealots” who defeated Hawaii’s Death With Dignity Act.²³ Members of the Hawaiian Partnership for Appropriate and Compassionate Care (HPACC) chuckled at this characterization.

The members and leaders of HPACC are people of power and position opposed to change. Hospice and medical associations are well-established and protective of their interests. Kelly Rosati’s group, The Hawaii Family Forum, is an affiliate of Dr. James Dobson’s Focus on the Family. It represents the interests of evangelicals and social conservatives on a number of issues and is characterized by a grassroots approach to politics. The Hawaii Catholic Conference is the political arm of the Roman Catholic hierarchy. The Catholic church earned the respect of the people of Hawaii for its charitable and educative work. Father Damien’s ministry to lepers on the island of Molokai is accorded a revered place in the history of the islands. Four of the five hospices in Hawaii are affiliated with the Catholic Church.

C. Hypotheses of Maurice Duverger

Maurice Duverger coined the term “dominant party” to describe a political party that outdistanced its rivals over an extended period of time and that identifies itself with goals, ideas, and style of a state.²⁴ He asserted that such parties are often found in postcolonial societies like Hawaii. The sons and daughters of the early missionaries formed an oligarchy of sugar and pineapple plantation owners made rich by the labor of immigrant workers. This group of wealthy land owners controlled most of the land in Hawaii. They imprisoned Queen Liliuokalani and set up the Republic of Hawaii in 1893. They conspired with expansionists during the Spanish American War to convince congress to annex Hawaii in 1898 and continued their rule during territorial days under the auspices of the Republican Party in Hawaii.

Statehood marked the beginning of the end for plantation rule. Japanese-Americans, who bore the scars of harvesting sugar cane on the plantations and proved themselves in combat during World War II, challenged the “Big Five” sugar companies and the Republican Party, and won. The new Democratic majority in the legislature had a vision of a prosperous and multicultural society. They passed social legislation dealing with taxes, access to education, and working conditions. The governorship and state senate, where committee chairpersons wielded enormous power, became bastions of the Democratic Party. This movement also had “an undercurrent of self-interest” that in the 1970s and 1980s predominated in the form of cronyism in the Democratic machine.²⁵

As suggested by Duverger, dominant party politics are characterized by the rivalry of factions centered around individuals. The leaders of these factions in Hawaii are more interested in rewarding friends and punishing enemies than engaging in ideological disputes. Incumbents are almost always reelected and primaries are all-important. Many Democrats run unopposed in the general election. Democrats in Hawaii are generally pro-business, some are committed liberals, and others are Republicans in disguise.

The voters of Hawaii, inured to the nepotism and corruption of the Democratic machine, react with indifference. Large numbers of eligible voters do not register and those who do often fail to vote. The people of Hawaii wanted a change and in 2002 they elected Linda Lingle (R) governor. The loss of this important and, in Hawaii, powerful office shocked Democrats and there are stirrings of reform, especially as the old guard retires and is replaced by a new generation of disadvantaged, who thus far have been interested only in single-issue politics. But I am getting ahead of myself. Theory stands on practice, the relevant facts, and events of the case.

III. Practice

Although the activities of advocacy interest groups and their coalitions remain important, the focus of action shifts to a new cast of characters after the introduction of Death With Dignity bills into the legislature of Hawaii. The story begins with the introduction of the first Death With Dignity bill into the Hawaii House of Representatives in 1975 by Representative Howard K. Oda. The bill asked that no active steps be taken to prolong the life of qualified individuals and made it legal for physicians to induce a painless death when appropriate. It languished in committee, as did subsequent bills until 2002, when the Hawaii state legislature came very close to passing the Death With Dignity Act. The last part of our tale chronicles the end-of-life issues and the difficulties faced by proponents of Death With Dignity.

A. The Struggle Begins (1998-2001)

A.A. Smyser, a member of Governor Cayetano’s Blue Ribbon Committee and a contributing editor to the Honolulu Star-Bulletin, supported end-of-life issues. Smyser argued doctor-assisted suicide was a loaded word. “It brings up images of jumping off high places, shooting oneself, drinking insecticide, drowning, setting oneself on fire, hanging, putting a plastic bag over one’s head or assembling a concoction of drugs.”²⁶ He described the issue as one that could be discussed with civility, unlike abortion, an issue characterized by an excess of emotions. The reason for the difference, according to Smyser, was that abortion tends to be a woman’s issue whereas death is democratic: it comes equally to everyone. Smyser differentiated between physician-assisted suicide (PAS), where a doctor prescribes a lethal drug and it is up to the patient to take it, and physician-assisted death (PAD), when the doctor administers a lethal agent to a patient who may be alert enough to make the request but not capable of carrying it out.²⁷

Six bills were introduced into the Hawaii state legislature to legalize or ban assisted suicide in 1998, but no hearings were held. In January 1999 the state legislature rejected a Death With Dignity bill sponsored by Governor Ben Cayetano, but did enact three significant end-of-life bills. The first strengthened living wills and durable power of attorney legislation and established penalties for noncompliance. The second required the Department of Motor Vehicles to ask all applicants to designate whether they had an advance healthcare directive, effective January 1, 2001. The third provided for reimbursement for hospice referral visits and room and board in hospice units. The 2001 legislature considered a bill introduced by Senate President Robert Bunda (D-Wahiawa-North Shore) that would allow physicians to assist patients suffering from irremediable conditions in ending their lives. HPACC opposed the bill and it died in committee.

B. Talking Story (2002)

Attempts to influence state legislators on end-of-life issues began in January 2002. Archbishop Francis Xavier DiLorenzo presided at the annual Red Mass, named after the vestments the celebrant wears. This mass is always celebrated the same week as the opening of the state legislature. The bishop’s office sent invitations to attend to public leaders from the executive, legislative, and judicial branches of the Hawaii state government, as well as representatives from Honolulu’s city government. Dr. Clementina Ceria spoke during mass on the need of the comprehensive long-term care of the aged.

Representative Eric Hamakawa (D-South Hilo-Puna) introduced the “Hawaii Death With Dignity Act” HB2487 into the House in February. The bill was similar to legislation in Oregon that allowed terminally ill patients to request a lethal prescription from their physician. Section 3(c) of the bill amended Hawaii Revised Statutes to indicate that the Act “shall not authorize mercy killing, assisted suicide, euthanasia, or the provision, withholding or withdrawal of healthcare to the extent prohibited by other statutes.”²⁸ The bill received an emotional three-hour hearing in the house Judiciary Committee. Representative Cynthia Thielen (R-Kailua) wept during the testimony of Kat Brady, who told the story of watching her mother writhe in pain for three months before dying. Brady hoped that “none of you ever have to watch someone you love go through something like this.”²⁹ Thielen replied that she had done so with her own mother. The committee passed the bill by a 10 to 1 margin, and it was approved by the full House on 7 March 2002.

The Hawaii Death With Dignity bill went to the Senate Health Committee, chaired by David Matsuura (D-South Hilo-Puna). Matsuura said he wouldn’t hold a hearing on the bill because there wasn’t enough time to consider the ramifications of such legislation. Reporter Richard Borreca quoted Matsuura as saying, “Absolutely, I will not hear assisted suicide. This dumb bill wasn’t even on our radar screen. I haven’t even looked at the measure or studied this measure yet. I can’t figure out what assisted suicide is.”³⁰ Matsuura later apologized for these remarks. Governor Cayetano hoped that Matsuura, an evangelical Christian, would rise above his personal beliefs and pressure from interest groups opposing the measure and schedule a hearing.

Jenny Nolan, in a National Right to Life Committee (NRLC) news release, described the Hawaii Death With Dignity Act as having “as many comebacks as a B-movie villain” and urged NRLC members to write Senator Matsuura asking him to table the bill.³¹ Matsuura responded by calling for a hearing at which representatives from both coalitions testified. In his opening remarks, Matsuura gestured to two stacks of correspondence on his desk and observed that the stack against Death With Dignity was significantly higher than the one for it.³² Both sides complained that some of the correspondence in the two stacks came from the mainland, an appeal to the widely held prejudice against outside meddling in island affairs. Afterwards, Roland Halpern of Compassion in Dying of Hawaii, researched the contents of the two stacks. He claimed that over 1,500 duplicate copies and several books “puffed up” the “against” stack and that actually there was more testimony in favor of assisted dying than against it.

Two days later Matsuura reconvened his committee and announced that he had tabled his revised bill indefinitely. He feared that if the revised bill was voted out of committee to the floor of the senate, the legislators who supported the Death With Dignity Act could easily rewrite the bill to reflect its original intent. He cited other reasons for tabling the bill. He wanted to see how a federal judge ruled on Oregon’s challenge to Attorney General Ashcroft’s ruling on the controlled substances used to hasten death, and noted deep divisions among the people of Hawaii on the issue. However, he was optimistic that the debate had produced some good in that it got everyone thinking and talking about end-of-life issues. Juliet Begeley, a researcher in the governor’s office, said she was disappointed but not surprised by Matsuura’s actions. Governor Cayetano personally asked Matsuura to reconsider his decision and permit his fellow senators to vote on the bill after District Court Judge Robert Jones issued a ruling favorable to Oregon’s suit against Attorney General Ashcroft.

On Tuesday, 30 April 2002, the Senate voted to discharge the original Hawaii Death With Dignity bill introduced by Representative Hamakawa from committee with a 15-10 vote and approved the bill on the second of three required readings by a 13-12 vote. The final vote was set for Thursday, 2 May. These decisions were not made without emotion. Senator Norman Sakamoto (D-Moanalua-Salt Lake), his voice quaking, recalled that when his father died of cancer, “He was suffering and it’s not easy watching someone you love suffer.”³³ He went on to say that, despite this experience, he did not support the bill. Senator Avery Chumbley (D-East Maui-North Kauai) replied that his father also died an agonizing death from cancer and that he supported the bill because it would have given his father a choice in how he died.

Kelly Rosati, spokesperson for HPACC, credited her opponents for being tenacious and charged they had waged a “stealth campaign” to get the measure to the floor of the senate.³⁴ She warned Hawaii would become the second state to approve assisted suicide legislation if opponents did not immediately mobilize like-minded voters. Representatives of the Catholic Church hand-carried letters from Bishop DiLorenzo to state senators urging them to vote no on the Hawaii Death With Dignity Act. Lobbyists from DWDH mounted a similar campaign, at times canvassing neighborhoods to solicit support for the bill. Supporters of both sides inundated legislators with personal visits, phone calls, e-mail, and faxes. When queried about the prospects of passage, Scott Foster of DWDH observed, “It’s anyone’s guess. It really is.”³⁵

The final debate on the Hawaii Death With Dignity bill took place during the third reading of the bill on Thursday, 2 May 2002, the afternoon of the final day of the session. Senator Jonathan Chun (D-Kauai-Niihau), an attorney, stood in opposition to the bill, charging that it would have an adverse impact on minorities and the disadvantaged. He quoted Diane Coleman, the founder of Not Dead Yet, that the promoters of assisted suicide are primarily “white, well-off, worried and well.”³⁶ Senator Hanabusa (D-Nanakuli-Waianae-Makaha), also an attorney, spoke in favor of the measure, recalling that during previous debates much was shared, “emotions were high and the stories were moving.”³⁷ Senator Bob Hogue (D-Kane’ohe-Maunawil-Enchanted Lake), speaking in opposition to the measure, related that his own family and his community were divided over the issue and that more discussion was needed.³⁸ Senator Avery Chumbley, speaking in support of the measure, apologized to Senator Matsuura, the speaker, for being emotional. Matsuura rejected his apology, stating, “You don’t need to apologize for your emotions.”³⁹ Chumbley then asked Matsuura to relay a message to Ruth Matsuura, the speaker’s mother. “She called me and asked me if I would reconsider my position. Please apologize to her because I won’t. But I have a tremendous amount of respect for Ruth, both as a doctor and a human being.”⁴⁰ Senator Chumbley went on to say there was no partisanship in the debate, citing a QMark poll that showed that both Democrats (75%) and Republicans (69%) supported the concept that an individual has the right to end his or her own life. He asserted that the poll showed that you did not have to be white, worried, and well off to support this concept. The same poll showed high levels of support among all ethnic groups.⁴¹

Senator Robert Tam (D-Nu’uamu-Mo’ili’ili-Manoa), better known to his colleagues as Mr. Sunshine, spoke against the measure, calling for further discussion among the people of Hawaii on the issue, stating, “Let’s talk story. Let us embrace relationships with communication.”⁴² When the call for the final vote came, three members who voted for the measure on Tuesday changed their votes and the Hawaii Death With Dignity Act was defeated by a 14-11 vote.

Both sides had insights on the bill’s defeat. Governor Cayetano was disappointed, but praised the high level of debate without partisanship. He argued that this was “a tremendous opportunity to raise the level of awareness on this subject” and predicted that a Death With Dignity bill would become law within five years.⁴³ Richard Borreca, Bureau Chief for the Honolulu Star-Bulletin, echoed these sentiments during an interview on National Public Radio. He noted that the debates in the House and the Senate did not follow factional or party lines and that legislators were often in tears as they told deeply felt stories of the deaths of their parents. Kelly Rosati of HPACC agreed that the “debate was remarkably profound on all sides,” but cautioned, “this is just the beginning.”⁴⁴ Dr. Gregory Hamilton, spokesperson for Physicians for Compassionate Care in Oregon, praised HPACC for defeating a “well orchestrated effort to pass an assisted-suicide law similar to Oregon’s,” claiming, “Hurray for Hawaii!”⁴⁵

C. Partisan Politics

Death With Dignity became a partisan issue in the primary and general elections of 2002. The Democratic Party platform contained a plank that stated, “Democrats support the right of people to choose death with dignity under appropriate safeguards.”⁴⁶ A former state party chairman failed in his effort to change the wording of the statement to a call for further education on end-of-life issues, insisting that the platform as written would cost Democrats votes in a close election year.

Most of the Democrats running in the Hawaii state primary supported the Death With Dignity Act. One of them, State Senator Lorraine Inouye, defeated David Matsuura for the Democratic nomination of the newly reapportioned Hilo-Hamakua senate seat. She believed that she won as much because of Matsuura’s inaccessibility to lobbyists and constituents as for his opposition to the Hawaii Death With Dignity Act.⁴⁷ Lt. Governor Mazie Hirono, the winner of the Democratic primary for governor, spoke out unequivocally for Death With Dignity. “We’re not talking about euthanasia here. We’re talking about an individual person’s decision while they are very lucid, and I believe that is one of the most fundamental decisions one can make about their lives.”⁴⁸

Republicans made sure their gubernatorial candidate, Linda Lingle, did not lose votes because of the party platform. In deference to her pro-choice stand, they deleted any mention of abortion or physician-assisted suicide in their platform and came out strong for private long-term care options, one of her favorite issues. Garret Hashimoto, chairman of the Hawaii Christian Coalition, was incensed. “It’s sad to say I don’t believe we have a Republican Party that supports Christian values and the Democratic Party certainly does not support (them).”⁴⁹ Lingle took a strong personal stand against Death With Dignity. “I don’t think people should be in the position of killing family members.”⁵⁰ After her election, Lingle promised that she would not sign such a bill unless it had the two-thirds vote necessary to override her veto.

D. Consequences of Change (2003)

A year makes a world of difference in politics. Governor Linda Lingle, an ardent opponent of Death With Dignity, replaced Governor Ben Cayetano, who labeled failure to enact such a bill his biggest disappointment during his term of office. HPACC was determined not to be taken by surprise in the 2003 legislative session. They launched a $40,000 campaign featuring radio, television, and print ads with the message, “The Cost of Caring Is Never Too High” the week before the legislature convened.⁵¹ Their ad featured their argument of a long-term physician against physician-assisted suicide. As part of the media campaign, Kenneth Zeri, president of Hospice Hawaii, spoke out against physician-assisted suicide, noting, “We don’t kill the sufferer.”⁵² Bishop DiLorenzo sent another letter to legislators stating his opposition to PAS, along with a book by Drs. Kathleen Foley and Herbert Hendin entitled, The Case Against Assisted Suicide: For the Right to End-of-Life Care.

State Senator Colleen Hanabusa reintroduced a Death With Dignity Act as part of the Hawaii Women’s Coalition’s legislative package. Both sides renewed their battle. Columnist David Shapiro of the Honolulu Advertiser advised his readers that the testimony of the dying in the last session of the legislature compelled him to change his mind and support the proposed legislation. He chastised governor Lingle for being inconsistent in her belief that individuals should enjoy freedom from government controls.⁵³ A counter-commentary entitled “Teach Options to Assisted Suicide Instead” by Drs. Herbert Hendin and Kathleen Foley, authors of the book given the legislators by Bishop DiLorenzo, argued that Oregon’s assisted suicide law “had failure built into it.”⁵⁴ HPACC concentrated its efforts bottling up Hanabusa’s Death With Dignity bill in committee and on passing a bill that exempted physicians and healthcare workers from prosecution for deaths as a result of proper palliative care. Scott Foster of DWDH acknowledged that the HPACC media campaign was having an effect and that no hearings would be held on Death With Dignity legislation. Foster’s portentous comment signals that this is an appropriate place to summarize.

IV. Conclusion

Three theories helped analyze the Death With Dignity debate in Hawaii: pluralism, critiques of pluralism, and Duverger’s hypotheses. Before drawing conclusions on the effectiveness of these theories, it is important to note that the dicourse in Hawaii was, for the most part, civil, especially if one compares it to similar debates in Oregon and elsewhere. Leaders of both sides talked with each other and reached compromises for the good of the people of Hawaii. The spirit of aloha was evident during my interviews, in which representatives of various interest groups talked openly and candidly about themselves and their opponents. There are several reasons for this: the debate in Hawaii took place in the legislature, whereas the discussion in Oregon was much more public, since the electorate voted on an initiative petition. Lastly, island people tend to get to know one another. There is an old saying in Hawaii, “Don’t talk stink about someone; you don’t know who they may be related to.”

A. Pluralism

People from both sides of the question lauded the quality and lack of partisanship in the debate. The frank and open discussion of a topic only whispered about previously brought about renewed emphasis on end-of-life care. The state legislature has implemented most of the recommendations of Governor Cayetano’s Committee on Death and Dying. Lobbyists united in a successful effort to persuade the legislature to fund hospices and to support living wills, medical powers of attorney, and counseling for the dying.⁵⁶ Although Kokua Mau, a public-private continuos-care project started by a grant from the Robert Johnson Foundation, does not support Death With Dignity, it nevertheless has made an impact on improving end-of-life care. Yet much remains to be done. A national coalition of end-of-life groups, Last Acts, conducted a study that showed that 33 percent of those who die in Hawaii’s healthcare facilities die in persistent pain that is easily treatable and indicated that Hawaii’s physicians lack adequate disciplinary oversight.⁵⁷

The discussion of the issues itself is also significant. The legislators of Hawaii wear flower leis on the floor of the House and the Senate, a visual reminder of the uniqueness of politics in Hawaii. The discussion of the Death With Dignity Act took place in a comfortable family atmosphere where people felt free to express their deepest emotions without censure. I doubt whether such a discussion could have occurred in a more partisan atmosphere. State legislators, like most people, are reluctant to discuss death. The fact that they could talk about emotional issues made them better people and better lawmakers. They experienced the anguish and denial that their constituents feel, and they wept. They are role models for all of us who have problems dealing with the death of a loved one.

Advocacy coalitions get people involved. They solicit members for financial support and as a means of influencing legislators. In so doing, they engender conversations among friends and neighbors. It is hoped that these discussions will have the same favorable effect that they had on Hawaii’s legislators. A survey commissioned by the Roman Catholic Church in Oregon showed that people do not make up their minds on end-of-life issues based on advertisements or sermons from the pulpit. They make up their minds by sharing experiences with friends and family.⁵⁸ Some believe that these discussions are the beginnings of a social movement that may significantly change people’s attitudes on death and dying.

B. Pluralist Critique

The members of the two coalitions and the interest groups of which they are composed are educated, passionate professionals. This natural elitism is constrained by the fact that both groups must appeal to the people to be effective. They need dues-paying members to contribute monetarily and provide services. Both sides realized that, “when there are scores of people jingling the phone lines and letters drifting into the office, elected officials tend to pay attention.”⁵⁹ Several state legislators complained about messages from their constituents that said vote my way or I won’t vote for you. Interest groups use extreme language and slanted statistics because they want to convince legislators and their own supporters of the justness of their cause.

Hunter and Lowi’s theories are at work in Hawaii in both coalitions. DWDH encourages the Hemlock Society to maintain a low-key supportive role in the fight for a more acceptable end-of-life option. The leaders of Compassion in Dying Hawaii are aware that ethnic groups express their feelings on death in different ways and strive to maintain a diverse membership. HPACC is conservative in the sense that they seek to preserve a certain set of ideals and values and view the ideas of their adversaries as modern, secular, and morally wrong. HPACC members have standing in the community and enjoy long established links to legislators. Primary among these are the continuing relationships enjoyed by the Roman Catholic Church, sometimes involving several generations of one family. Walter Yoshimitsu, for example, knew State Senator David Matsuura and his father, Dickie Matsuura, who also served in the state senate of Hawaii. Legislators listened to Bishop Di Lorenzo’s caution against moving too fast because they know and respect him.

C. Duverger

Hawaii is a dominant party state and the Democratic machine is characterized by factions. State Senator Colleen Hanabusa expressed her disappointment when David Matsuura lost his bid for reelection, even though they disagreed on the issue of Death With Dignity. More important than this one issue was the fact that Matsuura was part of her faction, which she had used to control the senate. Factions facilitate the trading of favors and compromise. Ideology is the enemy of factions because it forces legislators to form alliances in which negotiations are difficult, if not impossible. In combination with other factors, ideological disputes could lead to an end of the Democratic machine.

This issue by itself will not bring about a realignment of political parties in Hawaii. Senator Avery Chumbley quoted statistics from a March 2002 QMark poll that showed only a 6 percent difference between Democrats and Republicans on the question of whether an individual has the right to end his or her own life. It usually takes more than this to accomplish a realignment. However, one should never underestimate the power of the socially conservative wing of the Republican Party. They have demonstrated their ability to get voters to the polls, control state parties, and influence the national party. Their staunch opposition to Hawaii’s Death With Dignity Act contributed to a breakdown of Democratic unity and polarized the differences between the two parties. This, in conjunction with other events, could precipitate party realignment.

D. The Future

Death With Dignity bills will be introduced in future legislative sessions. If proponents are fortunate, there may be hearings, but given the strong opposition of Governor Lingle, it is unlikely any will pass during her four-year term. However, Death With Dignity proponents enjoy support from the press and if the public perceives an abuse of power, as they did with David Matsuura, proponents will be ready to take advantage of the political opportunity. A window of opportunity could come in the form of a lawsuit by the family of a patient whose physician did not prescribe adequate pain medication. Opponents, therefore, should keep their guard up and nurture established relationships, and not be afraid of using their best argument, the moral one. Both opponents and proponents of the Hawaii Death With Dignity Act must be careful of their rhetoric. Truth is the first casualty in an ideological debate. Nothing diminishes civil discourse more than people using terms like “band of zealots” or “killing patients.”

The people of Hawaii will benefit if both sides concentrate on building trust with legislators cooperating on end-of-life issues and educating the public. One way to do this is by emulating the discussions of Hawaii’s state senators on death and dying in 2002 that came from what one participant described as “the intellect and the heart.”⁶⁰ There are times when people should be emotional, especially in politics. Senator Tam referred to “talking story,” a form of communication in Hawaii that involves sharing personal experiences as a way of building strong personal relationships. The stories told by the people of Hawaii can be indirect and elliptical, but when one listens respectfully and non-judgmentally, they foster collaboration, turning “I” into “we.”⁶¹ Death comes to us all. What better way of preparing for that eventuality and building sound public policy than by embracing part of the culture of Hawaii.

Endnotes

¹Mele Manuscript Collection, HI. M. 70, Bishop Museum Archives, Honolulu HI.

²Mary Cooke, “Death With Dignity,” Honolulu Advertiser (24 June 1976), p. C1. See also The O File News Journal, Vol. 1, Issue 2 (March/April 2003), p. 1, and a letter by Laa’akea, (March 2002), Oregon Death With Dignity Website http://www.dwd.org/fss/stories.asp

³Yasim Anwar, “Difficult Decisions on Dying,” Honolulu Advertiser (16 February 2003). http://www.dwd.org/law/dwdinews.asp

⁴Jean Christensen, “Big Isle Tops Nation in Diversity,” Honolulu Star-Bulletin (31 March 2001), http://starbulletin.com/2001/03/31/news/story1.html

⁵US Census results for Hawaii, 2002, http://factfinder.census.gov/bf/

⁶Kathryn L. Braun, “A Review of End-of-Life Preferences in Hawaii,” Living and Dying With Dignity, undated pamphlet published by the Honolulu Star-Bulletin.

⁷Kathryn L. Braun, “Support for Physician-Assisted Suicide: Exploring the Impact of Ethnicity and Attitudes Towards Planning for Death,” The Gerontologist (February 2001), 41(1) 51.

⁸Kathryn L. Braun. Kokua Mau, Final Evaluation Report, January 1, 1999-December 31, 2001 (April 2002).

⁹Kathryn Braun suggested in an email (28 July 2003), that the statistics in the pamphlet and the evaluation report carry more weight scientifically than those in the Gerontologist article.

¹⁰The Hawaii Medical Association, Hawaii Family Forum, Hospice Hawaii, Hawaii Nurses Association, Healthcare Association of Hawaii, Hawaii Cancer Pain Initiative, Not Dead Yet, The Arc Hawaii, Hawaii Catholic Conference, Hawaii Right to Life, and The American Center for Law and Justice.

¹¹Interview with Kenneth Zeri and Walter Yoshimitsu (16 June 2003).

¹²Mike Yuen, “Groups Unite Against Assisted Death,” Honolulu Star-Bulletin (13 January 1999), http://starbulletin.com/1999/01/13/news/story3.html

¹³The Hawaii Chapter Association of Social Workers, Advocates for Consumer Rights, American Civil Liberties Union, Honolulu First Unitarian Church, Free Thinkers Maui, Hemlock Society, Humanists Hawaii, Kokua Council, Hawaii Compassion in Dying, Hawaii Physicians for Assisted Dying, and the Hawaii Religious Leaders for Assisted Dying.

¹⁴Nicholas T. Nikos, “Physician-Assisted Suicide Legislative Policy,” (Chicago: Americans United for Life, 2001), 3.

¹⁵Theodore Lowi and Benjamin Ginsburg, American Government (New York: Norton Co., 1996), 30.

¹⁶Pat Omandam, “Legislature Will Consider Euthanasia,” Honolulu Star-Bulletin (10 June 1998), http://starbulletin.com/98/06/10/news/story3.html

¹⁷Ibid.

¹⁸Death With Dignity Oregon Website, http://www.deathwithdignity.org/2009/06/16/death-dignity-around-us/

¹⁹Jeffrey M. Berry, The Interest Group Society (New York: Longman, 1997), 13.

²⁰Floyd Hunter, Community Power Structure (Chapel Hill: North Carolina U. Press, 1953), 228.

²¹Theodore Lowi, The End of Imperialism (New York: W.W. Norton Co., 1979), 60.

²²Email from Roland Halpern (20 July 2003).

²³Andi van der Voort, undated letter printed on Hemlock Society USA letterhead.

²⁴Maurice Duverger, Party Politics and Pressure Groups (New York: Crowell Co., 1966), 36.

²⁵Thomas P. Gill, “Hawaii’s Political Malaise,” The Price of Paradise II, ed. Randall W. Roth (Honolulu: Mutual Publishing, 1993), 210.

²⁶A.A. Smyser, “Better to Call It Doctor-assisted Death,” Honolulu Star- Bulletin (6 March 1997), http://starbulletin.com/97/03/10/editorial/smyser.html

²⁷A.A. Smyser, “Dying With Dignity Laws Put on Hold,” Honolulu Star-Bulletin (10 March 1998), http://starbulletin.com/98/03/10/editorial/smyser.html

²⁸Hawaii Death With Dignity Act HB2487, House of Representatives, Twenty-first Legislature (2002), State of Hawaii, Sec. 3c.

²⁹Will Hoover, “Assisted Suicide Bill Gets Hearing,” Honolulu Advertiser (24 February 2002), http://the.honoluluadvertiser.com/article/2002/Feb./24/In/In04a.html

³⁰Honolulu Star-Bulletin (1 Mar 2002), http://starbulletin.com/2002/03/01/news/story

³¹”Hawaii Assisted Suicide Measure Reaches Senate,” http://www.nrlc.org//news/2002/NRL04/hawaii.html

³²Email from Roland Halpern (24 July 2003).

³³Bruce Dunford, “Senate Revives Physician-Assisted Suicide,” Associated Press (1 May 2002), http://lexis-nexis.com/universe/document?_m=7275ff609fead6ad75545e3595ba9e54&

³⁴Holland Sentinel, “Hawaii Expected to OK Assisted Suicide,” (2 May 2002), http://www.holland.sentinel.com/stories/050202/new

³⁵Crystal Kua, “Senate Kills Death-With-Dignity Bill,” Honolulu Star-Bulletin (2 May 2002), http://starbulletin.com/Como/05/02/Neru/story3.html

³⁶Proceedings of the State Senate of Hawaii, twenty-first Legislature, Third Reading of H.B. 2487, H.D. 1. (3 May 2002).

³⁷Ibid.

³⁸Bruce Dunford, “Legislature Rejects Physician-Assisted Suicide,” Associated Press (2 May 2002), http://web.lexis-nexis.com/universe/document?_m=3ed.20553dd3c16da11316e97a212be93

³⁹Proceedings of the State Senate of Hawaii, twenty-first Legislature, Third Reading of H.B. 2487, H.D. 1. (3 May 2002).

⁴⁰Ibid.

⁴¹Ibid.

⁴²Ibid.

⁴³Lynda Arakawa and Kevin Dayton, “Assisted Suicide Rejected,” Honolulu Advertiser (3 May 2002), http://the.honoluluadvertiser.com/article/2002/May/03/in/in03a.html

⁴⁴Crystal Kua, “Death With Dignity,” Honolulu Star-Bulletin (3 May 2002).

⁴⁵Greg Hamilton, “Hawaii Rejects Assisted Suicide,” Press Release (2 May 2002), Physicians for Compassionate Care website, <http://pccef.org.news

⁴⁶Crystal Kua, “Death With Dignity Makes Platform,” Honolulu Star-Bulletin (June 2002), http://starbulletin.com/2002/06/02/news/story.html

⁴⁷Bruce Dunford, “Group Begins Media Campaign,” Associated Press (6 January 2003),

http://web.lexis-nexis.com/universe/document?_m=4d54d363c0627e4d672

⁴⁸Kevin Dayton, “Parties Split on Assisted Suicide,” Honolulu Advertiser (4 September 2002), http://starbulletin.com/2002/06/02/news/story.html

⁴⁹Crystal Kua, “Religion a Factor in State Elections,” Honolulu Star-Bulletin (16 September 2002), http://starbulletin.com/2002/09/16/news/story2html

⁵⁰Crystal Kua, “Death With Dignity Makes Platform,” Honolulu Star-Bulletin (3 June 2002), http://starbulletin.com/2002/06/02/news/story.html

⁵¹Advertisement Honolulu Advertiser, downloaded from HPACC website, www.hpacc.org

⁵²Lynda Arakawa, “Group Campaigns,” Honolulu Advertiser (7 January 2003), http://the.honoluluadvertiser.com/article/2003/Jan/07/In/In17ahtml

⁵³“Enact Death With Dignity,” 3 February 2003, http://the.honoluluadvertiser.com/article/2003/Feb/05/op/op04adavid.html

⁵⁴http://the.honoluluadvertiser.com/article/2003/Feb./09/op/op13a.html

⁵⁵Walter Yoshimitsu and Ken Zeri Interview (16 June 2003).

⁵⁶Jaymes Song, “Report Gives Hawaii Mixed Grades,” The Associated Press (17 November 2002)., http://web.lexis-nexis.com/universe/document?_m-7f790bb006c6_7bdfed5eb3cd_0034

⁵⁷“A Bad Year for End-of-Life Legislation in General,” Compassion in Dying of Hawaii Newsletter, Vol. 2, No. 1, 4.

⁵⁸Ed Langlois, “Pro-euthanasia Oregon Voters,” Catholic Sentinel (19 December 1997), p. 7.

⁵⁹Jenny Nolan, National Right to Life Committee News Release, “Suicide Measure Reaches Senate,” http://www.nrlc.org//news/2002/NRL04/hawaii.html

⁶⁰Proceedings of the State Senate of Hawaii, Twenty-first Legislature. Third Reading of H.B. 2487, H.D. 1 (3 May 2002).

⁶¹Richard Brislin, “Culture Clash,” Honolulu Star-Bulletin (2 June 2002), http://starbulletin.com/2002/06/02/business/brislin.html

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