A mile high and ten miles northeast of Lincoln, Montana, melting snow and mountain springs form the headwaters of the Blackfoot, made famous in the novella and film A River Runs Through It. Stand at the source, running icy and fast, and try to picture Hawaii. This water flows to the Pacific and could ultimately wash onto the red sand beach at Hana Bay.

Today, in Hawaii, a panel of experts convened at the state capitol. Legal, medical, elder care, legislative and end-of-life authorities concluded Hawaii law permits physicians to provide aid in dying subject to professional best-practice standards. How did they reach this conclusion? The journey begins in Montana.

The Montana Supreme Court’s ruling in Baxter v. Montana created a watershed between previous assisted-dying advocacy typified by Oregon’s Death with Dignity Act and the new era, in which patient choice becomes integral to the scope of medical practice at the end of life. Today the liberty springing from that Montana decision flows through Hawaii as newly affirmed choice at life’s end.

The Montana court recognized that requests for aid in dying were akin to other already-permissible end-of-life choices, as contemplated in the autonomy protected under the state’s Rights of the Terminally Ill Act. Hawaii law includes a version of this Uniform Health-Care Decisions Act, which allows patients to specify if and when they wish to refuse or withdraw life-sustaining medical care. Additionally, in 2004 Hawaii enacted the Pain Patient’s Bill of Rights, and in doing so recognized that inadequate treatment of pain is a significant health problem.

James Pietsch, a professor at the University of Hawaii’s Law School writing in 2004 for The Journal of Legal Medicine, noted a unique Hawaii law:

“[W]hen a duly licensed physician or osteopathic physician pronounces a person affected with any disease hopeless and beyond recovery and gives a written certificate to that effect to the person affected or the person’s attendant nothing herein shall forbid any person from giving or furnishing any remedial agent or measure when so requested by or on behalf of the affected person.”

Added in 1909, this provision aimed to give terminally ill patients the option to obtain treatment that had not yet been approved by the government. The 1909 provision, the Pain Patient’s Bill of Rights and the Uniform Health-Care Decision Act together give terminally ill patients significant freedom of choice to determine their course of medical care at the end of life and protection to physicians who provide that chosen care.

As in Montana, new law explicitly governing aid in dying was not necessary to enable dying patients to openly ask their physicians for aid in dying and for physicians to openly provide it. Most medical care is not governed by law, but by professional standards. Doctors may discontinue life-sustaining treatment such as respiratory support, pacemakers, dialysis and medication at the request of their patients.

Physicians in Hawaii have already witnessed an emerging standard of care that respects a patient’s autonomy and accepts life-ending practices.

The Hawaii Public Health Association (HPHA) along with the American Public Health Association (APHA) assert that people in Hawaii deserve a full range of options for palliative care and end of life, including aid in dying. That’s why the HPHA co-sponsored the panel discussion today. HPHA President Deborah Zysman says, “With proper safeguards in place, we believe that aid in dying poses no public-health risk, and that a mentally competent, terminally ill adult should be allowed to control the time, place and manner of his or her impending death.” Other major medical organizations also support open access to aid in dying: the American Medical Women’s Association (AMWA), the American Medical Student Association (AMSA) and the American College of Legal Medicine (ACLM). The American Academy of Hospice and Palliative Medicine (AAHPM) has shifted its stand from oppositional to neutral.

The lawyers and legislators on today’s panel concurred nothing in Hawaii law currently prohibits aid in dying. Patients and their doctors may make decisions governed by best medical practice, allowing them the opportunity to explore a range of patient-directed end-of-life choices. This is the model set by the Montana court in its watershed ruling. The liberty epitomized by the clear-flowing Blackfoot River gives hope to Hawaii residents facing their final days. They will soon have the same broad spectrum of end-of-life choices enjoyed by the people in Montana, Oregon and Washington.