Suicide lessons from Oregon

Oregon during fall rivals states more famous for the beauty of their dying foliage, according to the north-west state's official website. That claim may be contentious, but in one thing Oregon is definitely unique in the American landscape: it has a law that allows doctors to help people kill themselves.

Next month marks the tenth anniversary of the state's physician-assisted suicide (PAS) law. Although Oregon's Death with Dignity Act was initially approved by state voters in 1994, legal proceedings kept it from becoming operational until November 1997. The first recorded legal assisted suicide deaths began at the start of 1998. According to the Oregon Department of Human Services, which monitors the Act, in the nine years from 1998 through 2006 there were 292 such deaths. Information regarding the 2007 calendar year will be released in March 2008.

The assisted suicide movement itself has acknowledged
that physical pain is not the main reason for ending life. Oregon
assisted suicide patients have been described by their doctors as being
fiercely independent and controlling people. They fear dependency.
Control and choice are the key words now used in the promotion of
assisted suicide.

In the first four years (1998 to 2001) there were 91 deaths or about 23 a year. In the last five years (2002 to 2006) there were 201 deaths or about 40 a year. In 2006 there were 46 deaths; there were 65 prescriptions for lethal doses of secobarbital or pentobarbital written by 40 doctors. Currently about one in 700 deaths in Oregon is from assisted suicide.

Why have these Oregonians chosen to end their lives? Although the sponsors of the PAS law claimed that uncontrolled physical pain was the primary reason for legalizing assisted suicide, we have since learned that pain is not the main reason that some Oregonians have chosen it. The assisted suicide movement itself has acknowledged that physical pain is not the main reason for ending life. Oregon assisted suicide patients have been described by their doctors as being fiercely independent and controlling people. They fear dependency. Control and choice are the key words now used in the promotion of assisted suicide.

Less incentive to care

The arrival of "death with dignity" in Oregon has not created a health paradise. The national organization, Last Acts, issued a "report card" in November 2002 to states regarding their end-of-life care. Oregon was given a D grade for hospice care and an E grade for palliative care programs. There are concerns regarding pain management in Oregon. After four years of assisted suicide, an Oregon medical university study reported that there were almost twice as many dying patients in moderate or severe pain or distress as there had been prior to the law change.

Once a patient has the means to take his or her life, there is less incentive to care for the patient's symptoms and needs. A detailed report in the American Journal of Psychiatry in 2005 told of a depressed lung cancer patient in Oregon who had been committed to a mental hospital unit. During planning for his discharge, a palliative care consultant wrote that he probably needed attendant care at home, but providing for that additional care might be a "moot point" because he already had "life-ending medication" at home. His assisted suicide doctor did nothing for his pain and palliative care needs, but did offer to sit with him while he took the overdose. This seriously physically and mentally ill patient received poor medical advice and care because he had been prescribed lethal drugs.

An excuse for rationing care

Legitimising suicide for some can create danger for others. At a time of rising health costs administrators may build assisted suicide into their calculations.For instance, Oregon Medicaid covers the cost of assisted suicide, but not the cost of curative or local medical treatment for patients with cancer who have a less than a five per cent chance of living five years, even when that treatment can prolong valuable life. In 2003 Medicaid stopped paying for medicines for 10,000 poor Oregonians; this included patients with AIDS, those needing bone marrow transplants, people who are mentally ill and those with seizure disorders. In 2004 and the first half of 2005, an additional 75,000 Oregonians were cut from the health plan to keep the state budget balanced.

Even if an Oregon patient has Medicare or Medicaid coverage, there is limited access to health care. Sixty per cent of Oregon physicians limit or do not see Medicaid patients, and 40 per cent do not see Medicare patients. Seventeen per cent of Oregonians are without health insurance, and the share of Oregonians without health insurance has grown faster than in any other state over the past four years.

Abuse of the law

The so-called “safeguards” in Oregon’s law are meant to limit access. It is to be expected, however, that when controlling-type people -- as PAS patients in Oregon allegedly are -- come up against the requirements of the law, something has to give, and so the boundaries around assisted suicide in Oregon have stretched.

Some of the legal requirements are: being an Oregon resident, being mentally capable, being diagnosed with a terminal illness that will lead to death within six months, and self-administering the prescribed medication. Predictably, there are reported instances of these rules not being followed. In any case, there is no protection for the depressed or mentally ill: in recent years, only five per cent of those dying from assisted suicide had a mental health consultation. In 2006, only two of the 46 patients dying from assisted suicide were referred for psychiatric evaluation, yet depression is the most common cause of suicidal thoughts.

There are published reports about a patient diagnosed by a psychiatrist as having dementia, who still received a prescription for lethal drugs. The drug is supposed to be self-administered and ingested, and yet we have media reports of cases where that has not occurred because the patient was not capable of doing it. Other reports concern two patients whose lethal medication entered the body via a feeding tube, one of them a PEG tube (feeding straight into the stomach) placed for the sole purpose of taking the lethal medication. Terminally ill people are reportedly moving to Oregon from other states because of Oregon’s assisted suicide law.

Many doctors are writing prescriptions for lethal drugs to patients for whom they have not previously cared and some appear to be making it their specialty. Dr Peter Rasmussen reported that 75 per cent of the patients who come to him regarding assisted suicide are people he has never seen before. In the past four years, one doctor each year has written between six and eight prescriptions.

One thing Oregon’s PAS law has not done: it has not reduced other suicides. Between 1999 and 2002 the state had a rate of suicide (not counting deaths from assisted suicide) among those 65 years of age and older that was sixth highest in the nation and one and a half times the national average.

At the same time there is no real monitoring of Oregon's assisted suicides. In the last three years the prescribing doctor was present at the time the patient took the lethal dose of sleeping drugs in only 29 of the 121 deaths. Knowledge of complications for the other 92 patients is obtained second- or third-hand. Following David Prueitt's failed assisted suicide attempt in January 2005, the state Department of Human Services (DHS) publicly stated that they had "not authority to investigate individual Death with Dignity cases -- the law neither requires or authorizes investigations from DHS."

An isolated anomaly - for now

With majorities voting twice -- in 1994 and 1997 -- in favor of legalization, it is unlikely that Oregon will repudiate assisted suicide in the near future. However, the north-west state has failed to be the predicted harbinger of assisted suicide spreading to other states. In keeping with its geographic fringe location, Oregon represents a solitary anomaly in legalizing assisted suicide. Voter referendums and legislative bills similar to Oregon’s assisted suicide law have failed in Alaska, Arizona, California, Hawaii, Maine, Michigan, Washington and Wisconsin. The failure of assisted suicide extended across the Atlantic where an Oregon-type assisted suicide bill was rejected in the British House of Lords in 2006. In early October 2007 the Washington State Medical Association rejected a proposal to be neutral in this area and strengthened its policy of opposition to PAS.

Why have PAS bills failed in other states? Because of the concern of a broad coalition of health care professionals, hospice workers, disability rights advocates, minority groups, pro-life advocates, and various moral and ethical leaders who have vigorously opposed the legalization of assisted suicides in these political jurisdictions.

They are concerned about the impossibility of containing assisted suicide once it starts; about the financial inequalities in society and about fair access to medical care by the disadvantaged. Above all, they worry that the so-called “safeguards” of Oregon’s assisted suicide law are being disregarded.

Kenneth R. Stevens Jr, MD, is Vice-President of the Physicians for Compassionate Care Education Foundation. The foundation promotes compassionate care for severely-ill patients without sanctioning or assisting their suicide. Members affirm that all human life is inherently valuable and that the physician’s roles are to heal illness, alleviate suffering, and provide comfort for the sick and dying.


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