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In 1994, Oregon voters approved the Death with Dignity Act (DWDA) by a vote of 51% to 49%. It became effective in 1998, surviving court challenges and a repeal effort, to make Oregon the first state in the country to legalize physician-assisted suicide (PAS).1 The law allows physicians to prescribe life-ending drugs that are requested by terminally ill patients with six months or less to live. In the nine years since then, DWDA records show that 455 people have requested lethal drugs from their physician and 292 people have died from using them. The yearly numbers continue to rise, beginning with 16 deaths in 1997, increasing to 38 in 2005, and reaching 46 deaths in 2006.2 Although these records show that relatively few Oregonians choose to use this option, the lack of accountability and safeguards in the process have many people concerned that the numbers are not telling the whole story. In addition to that, disturbing trends appear to be developing.
For example, only 17 complications have been reported in the 292 deaths, and 16 of these were regurgitation. However, in the Netherlands, where they have had many years to work on overcoming complications in assisted suicide, serious complications are still reported. In fact, a study found that Dutch doctors feel the need to intervene (by giving lethal injections) in 18% of cases because of complications or problems. The lack of reported complications in Oregon has caused even pro-assisted suicide physicians to question the credibility of Oregon’s reported data.3
One of the reasons to suspect the accuracy of the data is that the prescribing physician is not required by law to be present when the drugs are taken. Since 2001, when this data was first collected, prescribing physicians had only been present at 29% of the deaths. The recording of complications is therefore dependent upon the self-report of a physician who, in most cases, was not even present, and who must rely on second-hand information or guesswork to file a report. The Oregon Department of Human Services (DHS), which collects the information, must depend on the word of the doctors for the reliability of their data and “it has no authority to investigate individual Death with Dignity cases.”4
Even more chilling is the fact that the Death with Dignity Act applies no penalties to doctors who do not report that they have prescribed lethal drugs for the purpose of suicide. This means that there is no way to know for sure how many assisted-suicide deaths may actually be occurring in Oregon. Nor is there any way to know whether the prescribed drugs are being made available to people other than the patient who requested them. Only 64% of patients who have received the prescriptions are known to have died from taking them. What becomes of all the other deadly drugs? It is possible the prescriptions have never been filled, or maybe the lethal drugs are sitting in medicine cabinets unused, but clearly there is the potential for accidents, and the law provides very little safeguard from abuse. So far, no one has been disciplined for disregarding the safeguards that the law does provide. Complications are not investigated and likely not reported in many cases, and the reality is DHS “has no regulatory authority or resources to ensure compliance with the law.”5
According to the Oregon data, the majority of patients who choose assisted suicide have some type of cancer, have a median age of about 70 years, are overwhelmingly white (98%), somewhat more likely to be male (57%), have had at least a partial college education (63%), are enrolled in hospice care (86%), and die at home (93%).6 The most common concerns given for choosing assisted suicide are “losing autonomy” (87%), being “less able to engage in activities making life enjoyable” (87%), and “loss of dignity” (80%). (The last category was added in 2003.) No category is provided to indicate whether or not the patient might be depressed, yet all of these concerns have much to do with a patient’s gloomy appraisal of life, a possible indicator of treatable depression. Still only 4-5% of patients were referred for psychiatric evaluation from 2003 to 2006, having dropped from 37% in 1999, to 13% in 2002 and reaching its lowest point of 4% in 2006. This indicates a weakening response on the part of prescribing doctors to ensure that the patient is truly capable of making such a decision.
There may be a reason for this trend. One of the safeguards touted by the promoters of assisted suicide was that this decision would be made between the patient and his long-time trusted doctor. This familiar doctor would discuss all other options with the patient and would be able to evaluate the patient’s true physical and psychological state. To prevent hasty decisions, the law requires a patient to make two oral requests for the lethal drugs, at least two weeks apart, before the physician can prescribe them. Yet for the past 6 years, the minimum recorded duration for a patient-physician relationship has been 1 week or less. Not only does this indicate that at least some doctors are not following the law’s requirements, but with a median duration of about 12 weeks, it means that most patients are not receiving these prescriptions from a trusted doctor who knows them well.
In fact, many physicians are unwilling to write lethal prescriptions, causing at least one HMO to make an email plea to enlist doctors who would be willing to act as the “attending physician” for patients requesting assisted suicide.7 And nurses’ organizations admit to sending patients to an assisted-suicide advocacy group when their own doctor does not want to participate.8 These patients then find a doctor through the advocacy group Compassion and Choices (formerly called Compassion in Dying, until it merged with the Hemlock Society in 2005), which sees “almost 90% of requesting Oregonians.”9
Not only are assisted-suicide patients becoming disengaged from their trusted doctors and relying heavily upon the aid of an assisted-suicide advocacy group, but HMO’s are becoming involved in administering assisted suicide, a much cheaper option for them than paying for longer-term palliative care that would focus on alleviating a patient’s pain.
It is much more cost effective and easier to let people kill themselves, and it can be rationalized as a compassionate approach. One of the primary arguments for assisted suicide is the ending of unbearable physical pain. Experience in The Netherlands, where euthanasia is legal, is revealing. Concern that pain will become unbearable is common, this being a worry in one-third or more of such patients. However, the Dutch experience is that of those actually requesting euthanasia, only 5% list physical pain as their major reason, and typically when pain is controlled they change their mind. As noted above, loss of autonomy and other psychologically “painful” concerns are the overwhelming majority of reasons given.
All in all, there are many troubling aspects of Oregon’s assisted suicide law, and yet several states have tried to follow suit with nearly identical bills. California, Hawaii, Arizona, Vermont and Wisconsin have all faced assisted-suicide bills in their legislatures this year, and for some of these states it has been an ongoing attempt for several years. As assisted-suicide proponents continue to lobby for this legislation, their language has evolved into less threatening-sounding terms. Rather than “physician assisted suicide,” the phrase is “physician aid in dying” or PAD, so physicians now “induce PAD.” In fact, the DHS has been threatened with litigation if the state continues to use the word “suicide.” Other euphemisms include “patient choice,” “control at end of life,” “assisted death” and “death with dignity.” This is all part of a program to help people think of it as a compassionate approach to death.
Where will the Oregon experiment go from here? The Netherlands’ experience has shown that acceptance of assisted suicide can lead to involuntary euthanasia of the disabled and dying, which can lead to legal euthanasia. This melds easily into illegal but accepted euthanasia of disabled and dying babies. It is then just a small baby step to legalize the infanticide of such “suffering” little ones. This is where the thinking in The Netherlands has gone in the past 30 years. As Wesley J. Smith, an anti-euthanasia advocate, author, and an attorney for the International Task Force on Euthanasia and Assisted Suicide, says about the euthanasia movement: “euthanasia and assisted suicide have gone…from the unthinkable, to the debatable, to the justifiable, on its way to unexceptional.”
We would be wise to keep a very close eye on Oregon.10
1. State of Oregon: Death with Dignity Act. Accessed at: http://www.oregon.gov/DHS/ph/pas/
2. Summary of Oregon’s Death with Dignity Act – 2006 Annual Report. Accessed at: http://www.oregon.gov/DHS/ph/pas/docs/year9.pdf
3. International Task Force on Suicide and Euthanasia, Nine years of Assisted Suicide in Oregon, April 30, 2007; p. 3. Accessed at: http://www.internationaltaskforce.org/orrpt9.htm
4. Ibid, p. 2.
5. Ibid, p. 1.
6. Oregon’s Death with Dignity Act – 2006 Annual Report, Table 1. Accessed at: http://www.oregon.gov/DHS/ph/pas/docs/yr9-tbl-1.pdf
7. International Task Force on Suicide and Euthanasia, Nine years of Assisted Suicide in Oregon, April 30, 2007; p. 5.
8. International Task Force on Suicide and Euthanasia, The Oregon Experience, March 2006; p. 3. Accessed at: http://www.internationaltaskforce.org/orexp.htm
10. Smith, Wesley J., The Future of Assisted Suicide and Euthanasia, First Things, April 2007. Accessed at: http://www.discovery.org/scripts/viewDB/index.php?command=view&id=4000