Euthanasia and Assisted Suicide Today

Euthanasia and Assisted Suicide Today

Euthanasia and Assisted Suicide Today

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I had done some research about eutha- asia but I had been under the impression that, even though there were three national euthanasia groups op- erating in the United States, any real threat of euthana- sia was in the far distant future. That all changed when I attended the World Federation of Right-to-Die Soci- eties’ biennial conference in Nice, France. In attendance were six hundred people from nineteen countries, in- cluding many leaders in law, medicine, and politics. As they discussed their plans and current practices, it be- came abundantly clear that the euthanasia movement was well-organized and well-positioned to influence so- cietal change.

Between 1984 and 1990, when discussing the poten- tial threat of euthanasia with individuals and groups, I usually heard people say, “It can never happen here.” However, in the early 1990s, Jack Kevorkian and his activities became front-page news and Oregon trans- formed the crime of assisted suicide into a “medical treatment.” Attitudes changed. The prevailing sentiment became, “Legalization of euthanasia throughout the United States is inevitable.” Both views were wrong. It can happen here, but legalization throughout the United States is not inevitable.

It is certainly true that euthanasia and assisted-sui- cide deaths are taking place across the country. Some doctors do intentionally end their patients lives; others prescribe medications along with a wink, a nod, and the words, “If you take more than x number of these cap- sules, you’ll die.”

Right-to-die advocates argue that, since doctors are intentionally ending their patients’ lives now, it would be far better to legalize the practice so that there could be safeguards. Such reasoning implies that, if members of a profession break the law, the law should be changed to permit the activity under certain guidelines. This leads to ludicrous results. For example, since some teachers become sexually involved with their young students, pedophilia should be legalized so that it could be car- ried out under carefully crafted guidelines and safe- guards.

Furthermore, the pro-legalization-with-safeguards- and-guidelines argument presupposes that doctors who kill and pedophiles who act on their impulses would abide by “guidelines.”

Far from creating a safer environment for patients and students, legalization of euthanasia and pedophilia would create an atmosphere in which acts that are cur- rently criminal would be viewed as acceptable. The ap- palling would become the appealing.

If such a change were to occur, doctors and teachers, particularly those who are just entering those profes- sions, would begin their careers in an atmosphere where it is all right to kill a patient or have sex with a child– as long as certain guidelines were followed. The law is, indeed a great teacher. And, in the view of many, legal- ity and morality are synonymous. Transforming crimi- nal acts into acceptable behavior carries grave risks for society.

As of 2005, Oregon, the Netherlands, and Belgium are the only jurisdictions in the world where euthanasia or assisted suicide are considered medical treatments. They are anomalies and will remain so if, and only if, all who seek to protect the vulnerable know what is at stake and work to maintain current legal barriers against medical killing. Understanding the vocabulary, facts, and strategy used in this battle is paramount to main- taining those barriers.

Definitions and Current Status This discussion is limited to the future of euthanasia

and assisted suicide as they are legally defined in the United States. It does not address removal of life sup- port, the topic of food and fluids, or other end-of-life issues. The words “euthanasia” and “assisted suicide” are often used interchangeably, but they have very dif- ferent legal meanings.

In the United States, “euthanasia”–called “mercy killing” in the past–refers to intentionally, knowingly, and directly taking an action for the purpose of causing the death of another person (e.g., a physician deliber- ately kills a patient with a lethal injection or a person

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smothers a spouse with a pillow.) Euthanasia is com- mitted when someone other that the person who dies performs the last act, without which death would not occur. Euthanasia is considered homicide in every state.

“Assisted suicide” refers to intentionally and know- ingly providing the means of death to another person so that the person can use it to commit suicide (e.g., a physician writes a prescription for an intentional drug overdose so that a patient can die of the overdose or one person helps another commit suicide using a plas- tic bag and helium gas.) Assisted suicide takes place when the person who dies takes the last act, without which death would not occur. In 1994, Oregon’s “Death with Dignity Act” transformed the crime of physician- assisted suicide into a medical treatment for adults who have a predicted life expectancy of six months or less.

In the Netherlands, both euthanasia and assisted sui- cide are considered medical treatments and are legal as long as they are “committed by a physician who has met the requirement of due care” and are done at the patient’s explicit request. If a doctor ends a patient’s life without the patient’s request, the death does not fall within the technical definition of euthanasia. In- stead, it is referred to as physician-assisted dying with- out explicit request. Thus, in Holland, reports do not refer to involuntary or non-voluntary euthanasia.

To be eligible for euthanasia or assisted suicide in the Netherlands, patients need not be adults or suffer- ing from any life-threatening physical illness. Minors between sixteen and eighteen may request that their lives be terminated, and, although they must be consulted, parents and guardians have no authority to prevent the requested death. Children between the ages of twelve and sixteen may request euthanasia or assisted sui- cide but a parent or guardian must agree with the decision. Age requirements are extremely flexible, so much so that articles in the September 2005 edi- tion of the Archives of Pediatric and Adolescent Medi- cine sought to address the question of the role of eutha- nasia in the context of pediatric care and noted that half of all Dutch pediatricians are willing to actively end a child’s life.

In Belgium, euthanasia and assisted suicide are legal for adults and emancipated minors. As in Oregon and Holland, the deaths are to be induced or assisted only by physicians. However, a study published in 2004 in the Journal of Advanced Nursing found that nurses in Belgium administer the majority of lethal injections.

Current activities of right-to-die activists in the United States center on changing laws to permit eutha- nasia and assisted suicide as defined above. An exami- nation of the strategies used by euthanasia and assisted- suicide proponents is also a key element in successfully

combating what is euphemistically called the “death with dignity” movement.

Voter Initiatives On November 7, 2000, Maine citizens were asked to

approve the “Maine Death with Dignity Act.” The bal- lot question was, “Should a terminally ill adult who is of sound mind be allowed to ask for and receive a doctor’s help to die?”

Voters who took the time to wade through the measure’s small print found that what was called “a doctor’s help to die” was not a commitment to provid- ing care, concern, and pain control as long as the pa- tient lived, but a prescription for a fatal drug overdose. The measure failed.

After the vote, most opponents of assisted suicide breathed a sigh of relief and then promptly turned to other matters, but the reaction among those who favor assisted suicide was far different. They didn’t fold up their tents. They didn’t see the situation in Maine as a done deal. They looked at what had happened, saw it as a temporary setback, regrouped, and kept on working.

This pattern has been repeated over and over again in the battles that have taken place in recent years. “Out of sight, out of mind” seems to be the operative phrase among those who oppose euthanasia and assisted sui- cide. “If at first you don’t succeed, try, try again” de- picts the response of proponents.

Those who seek to legalize euthanasia and assisted suicide pursue their agenda with great dedication and zeal, coupled with savvy public relations instincts and a strategy that launches multi-directional attacks on state laws banning both practices.

Maine was not the first place where attempts were made to change the law by a direct vote of the people. Voter initiatives to legalize “aid-in-dying” failed in Washington (1991) and in California (1992). Unlike more recent proposals, those “aid-in-dying” measures would have permitted both euthanasia and assisted sui- cide. Euthanasia activists attributed their defeats in Washington and California to opponents’ ads depicting a syringe-wielding physician preparing to administer a lethal injection. So they went back to the drawing board and drafted a new “softer, gentler” bill.

Oregon That new bill, which became Measure 16. the “Or-

egon Death with Dignity Act,” went through a number of drafts and, in its final version, became the country’s first assisted-suicide bill, explicitly prohibiting eutha- nasia in general and the lethal injection in particular. By limiting the proposal to assisted suicide only, the illusion of patient control was conveyed.

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The measure’s supporters portrayed opponents as religious zealots who were trying to impose their views on everyone and depicted themselves as kind, compas- sionate individuals who wanted nothing but the right to end intolerable pain by gentle, legal means.

The campaign’s centerpiece was a 60-second televi- sion commercial that featured Patty A. Rosen, a former nurse who told a story of helping her daughter to die. “So I broke the law and got her the pills necessary. And she slipped peacefully away,” Rosen said, as she pleaded with viewers to make such actions legal by approving Measure 16.

The ad was powerful, compelling. Over and over, in interviews about the Oregon proposal, Rosen repeated the story of how she gave Jody the pills and “she slipped peacefully away.” There was only one problem. The story wasn’t true.

Two years earlier, during the California campaign to legalize both euthanasia and assisted suicide, Rosen told the audience at a Hemlock Society conference in Long Beach, California that she had given her daugh- ter pills but they hadn’t worked. Explaining that it had been necessary to give her daughter a lethal injection, Rosen said, “So she went to sleep. I didn’t know about plastic bags. I wish I had. [I]t seemed to be backfiring. And I was fortunate enough at the very last to be able to hit a vein right and say, ‘Bye, Jody. See you later.’”

Discrepancies between the pills-only and the lethal injection versions of Rosen’s story went unchallenged until three days before the vote when an article in an inside section of the Oregonian carried Rosen’s admis- sion that the commercial was inaccurate. Based largely on the “peaceful pill” fabrication, Measure 16 passed, making Oregon the only state where, by law, a doctor can prescribe an intentional lethal dose of drugs. Soon the Oregon Medicaid program announced that it would pay for assisted suicide for poor residents as a means of “comfort care.”

Michigan When Oregon’s Death with Dignity Act went into

effect in 1997, assisted-suicide activists thought other states would fall like dominoes. They selected Michi- gala as their next target, introducing the “Terminally I11 Patient’s Right to End Unbearable Pain and Suffering Act.” Unlike the relatively short Oregon law, “Proposal B,” as it was labeled on the Michigan ballot, was a 12,000-word disaster for assisted-suicide backers. The proposal was so poorly written that even many who favored assisted suicide found it flawed.

There were other problems as well for its support- ers. A broad-based coalition against the measure pre- vented assisted-suicide activists from using the religion

bashing that had been so effective in Oregon. Large minority populations in Detroit were very much op- posed to assisted suicide. And the cost of gathering sig- natures to place the measure on the ballot bad left little funding to wage an effective media campaign.

Although early public opinion polls had indicated that the majority of Michigan voters favored assisted suicide, the proposal was resoundingly defeated on November 3, 1998, by a vote of 71 to 29 percent. How- ever, as with the losses prior to their Oregon success, those who seek to make assisted suicide just another medical option used the abysmal failure in Michigan as a learning experience–and looked ahead, this time to Maine with a ballot initiative for 2000.

Maine Conditions in Maine seemed favorable for passage

of the “Maine Death with Dignity Act,” which appeared on the ballot as “Question I.” The proposal was virtu- ally identical to the Oregon law. Maine’s demographics were similar to those of Oregon and, because the state is relatively small, the cost of the campaign would be only a fraction of that in Michigan.

The underlying theme used by the measure’s spon- sor, Mainers for Death with Dignity (later called “Yes on 1”), was that Maine should follow Oregon’s lead. During the course of the campaign, assisted-suicide supporters from Oregon pitched in to help. Dr. Katrina Hedberg (Oregon’s chief epidemiologist who co-au- thors Oregon’s official assisted suicide reports), Ann Jackson (executive director of the Oregon Hospice Association), Barbara Coombs Lee (a chief author of the Oregon law and executive director of the as- sisted-suicide advocacy group Compassion in Dying, now called Compassion and Choices), and former Or- egon governor Barbara Roberts all traveled to Maine to assure voters that Oregon’s law was working well and was problem free.

However, the “No on I” campaign, made up of an impressive, broad-based coalition to oppose the mea- sure, used effective research and carefully designed material to counter erroneous claims of a problem-free Oregon law. One television ad featured Oregon physi- cian Thomas Reardon, immediate past president of the American Medical Association. In it, Reardon described Oregon’s problems and complications with assisted sui- cide. He related the story of a 911 call made by a panic- stricken family member when the lethal prescription caused complications. The ad concluded with Reardon saying, “And I don’t want Maine to make the same mistake we did.”

The No on 1 ads were so effective that the Yes on 1 camp tried to have them taken off the air. When they

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were unsuccessful, Yes on I enlisted the aid of Oregon’s governor, John Kitzhaber, to appear in an ad to “set the record straight” about the Oregon law. “Here’s the truth,” Kitzhaber said. “It’s working well.” He insisted that no assisted suicide under the Oregon law had ever resulted in complications warranting a 911 call. But the No on I campaign was able to produce documentation that the case had been the subject of a two-part article in the Oregonian.

Support for Question 1, which had been at 71 per- cent in August, fell as Mainers learned more about the proposal, and it ultimately failed to pass by a vote of 5 !.-49 percent.

But, true to pattern, assisted suicide advocates re- fused to give up. The Yes on 1 committee reorganized as the “Maine Death with Dignity Center (MDDC),” a 501 (c)(3) corporation. Funded by the Hemlock Soci- ety, the MDDC staff and board–all activists from the Question 1 campaign–announced that they were “com- mitted to continuing the movement” to legalize assisted suicide in Maine.

Legislative Proposals In addition to the initiative process, the legislative

route is another avenue being taken to promote assisted suicide. “In what states should proposals to legalize as- sisted suicide be expected?” is a fairly common ques- tion. The answer is simple. Every state is likely to be faced with such a measure, sooner rather than later.

Since passage of Oregon’s assisted-suicide law in November 1994, assisted suicide and/or euthanasia measures have been introduced in more than 21 states. Not one has passed.

However, passage is not always the goal of propos- ing a law to permit assisted suicide. Those who favor the practice acknowledge that the mere introduction of a legislative proposal is beneficial since, when a “death with dignity” bill is introduced, media coverage fol- lows. This presents an opportunity to feature an emo- tional appeal from a patient who pleads for the “right” to assisted suicide.

Then, after the initial flurry of stories, most bills linger in committee until their demise at the end of a legislative session and coverage fades. But, the enve- lope has been moved. A step has been taken to build public support by creating the illusion that legalization of assisted suicide is a compassionate solution to a heart- wrenching situation. Additionally, the constant barrage of proposals along with their accompanying attention- grabbing stories can create the illusion that assisted sui- cide is inevitable, that it’s not going to go away, and that the rest of the country will eventually follow Oregon’s lead. Since passage of Oregon’s law, assisted

suicide bills have made it out of legislative committees in only two states–Hawaii and California.

Assisted-suicide advocates targeted the Hawaii Leg islature in the hope of making Hawaii the second state after Oregon to legalize physician-assisted suicide. In 2002, the “Hawaii Death with Dignity Act”–modeled after Oregon’s law–passed the House but was defeated in the Senate. It was reintroduced in each subsequent year. Not only has it failed each time but, in 2005, it did not even survive its first hearing before the House Health committee.

California, however, is another story. Euthanasia and assisted-suicide activists see Califc~rnia as the prize. They believe that, if they can prevail there, they will be on the road to death on demand in every state. A current California proposal, called the “California Compassion ate Choices Act,” is virtually identical to Oregon’s law. In early 2005, the measure (AB 654) passed out of com- mittee but, due to lack of support in the full Assembly, its authors, Patty Berg and Lloyd Levine, pulled the measure. Hoping for a better outcome in the Senate, they engaged in a back room maneuver called “gut and amend.” This move (which is relatively common in California politics) allows a sponsor to take a law that has passed, “gut” it by removing all of its language, and then “amend” it by inserting totally different lan- guage.

In this case, a measure to provide health care for the poor (AB 651) had passed the Assembly and moved on to the Senate. Levine then gutted the bill, deleting its title and text, leaving no mention of health care for the poor. Then he amended it, inserting the title and text of the failed assisted-suicide bill. Since the bill numbered AB 651 had already passed the Assembly, the bill bear. ing that number could be considered by the Senate, even though its content was entirely different from that approved by the Assembly.

To Berg’s and Levine’s dismay, the Senate was not as supportive as they had hoped. Before any vote could be taken, the authors changed both AB 654 (still in the Assembly) and AB 651 (still in the Senate) into two- year bills. That means that the authors still have to gar- ner support for one of the two identical bills, but their deadlines for doing so are extended to 2006.

Yet, even with this measure pending, assisted-sui- cide supporters are not playing a wait-and-see game. They are planning ahead to get another state–any state- – into their win column. A proposal, called “Oregon plus one,” circulating among fight-to-die activists in mid- 2005, outlines plans to target other states in the near future, with emphasis on Washington state.

As a highlight of every campaign, Oregon is used as the poster state. Invariably, official reports are employed

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to show that “the law is working well.” Thus, it is im- portant to examine both what is contained and what is omitted in Oregon’s official reports.

Oregon Reports Under Oregon’s law permitting physician-assisted

suicide, the Oregon Department of Human Services (DHS~–previously called the Oregon Health Division (OHD)–is required to collect information, review a sample of cases, and publish a yearly statistical report. In the first seven years during which the “Death with Dignity Act” was in effect, seven official reports were published. However, due to major flaws in the law and the state’s reporting system, there is no way to know for sure how many or under what circumstances pa- tients have died from physician-assisted suicide.

Assisted-Suicide Deaths Reported Official reports state that there have been 208 deaths

in the first seven years since the law went into effect. Those, however, are the reported deaths. The actual number of deaths is unknown. The latest annual report indicates that reported assisted-suicide deaths have in- creased by more than 225 percent since the first year of legal assisted suicide in Oregon. The numbers, how- ever, could be far greater. From the time the law went into effect, Oregon officials in charge of formulating annual reports have conceded that there is no way to know if additional deaths went unreported because Or- egon DHS has no regulatory authority or resources to ensure compliance with the law.

The DHS has to rely on the word of doctors who prescribe the lethal drugs. Referring to physicians’ re- ports in its March 1999 CD Summary, the state report- ing division admitted: “For that matter the entire ac- count [received from doctors] could have been a cock-and-bull story. We assume, however, that physi- cians were their usual careful and accurate selves.” The Death with Dignity law contains no penalties for doc- tors who do not report prescribing lethal doses for the purpose of suicide.

Complications Occurring during Assisted Suicide Official reports state that there have been ten in-

stances of vomiting, but no other complications associ- ated with physician-assisted suicides. Those are the re- ported complications. The actual number of complications is unknown. Prescribing doctors may not know about all complications since they are often not present when the deaths occur. During the seventh year, physicians who prescribed the lethal drugs for assisted suicide were present at fewer than 16 percent of re- ported deaths so the information provided by doctors

may come from secondhand accounts of those present at the deaths or may be conjecture.

The fact that official reports do not reflect what is actually happening is emphasized when news accounts of complications, none of which were reflected in offi- cial reports, are taken into account:

�9 In 1999, the Oregonian described the death of Patrick Matheny. Matheny received his lethal pre- scription from Oregon Health & Science Uni- versity via Federal Express. He had difficulty when he tried to take the drugs four months later. His brother-in-law, Joe Hayes, said he had to “help” Matheny die. According to Hayes, “It doesn’t go smoothly for everyone. For Pat it was a huge problem. It would have not worked without help.”

�9 The following year, the Oregonian and other Port- land-area news outlets carried accounts of an- other case where complications occurred. Speak- ing at Portland Community College, pro-assisted suicide attorney Cynthia Barrett described a botched assisted suicide. “The man was at home. There was no doctor there,” she said. “After he took it [the lethal dose], he began to have some physical symptoms. The symptoms were hard for his wife to handle. Well, she called 911. The guy ended up being taken by 911 to a local Portland hospital. Revived. In the middle of it. And taken to a local nursing facility. I don’t know if he went back home. He died shortly–some…period of time after that…”

Overdoses of barbiturates are known to cause vomiting as a person begins to lose conscious- ness. The patient then inhales the vomit. In other cases, panic, feelings of terror and assaultive be- havior can occur from the drug-induced confu- sion. But Barrett would not say exactly which symptoms had taken place in this instance. She has refused to discuss the case since her revela- tions at the community college.

�9 In 2005, David Prueitt took a prescribed lethal dose in the presence of his family and members of Compassion & Choices (C & C). [C & C is the name of the merged Compassion in Dying and Hemlock Society organizations.l After be- ing unconscious for 65 hours, he awoke. It was only after his family told the media about the botched assisted suicide that C & C publicly ac- knowledged the case. DHS issued a release say- ing it “has no authority to investigate individual Death with Dignity cases.”

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Another reason for skepticism about Oregon’s official claims that complications are limited to vomiting is the experience in the Netherlands where assisted-suicide complications and prob- lems are not uncommon. For example, in 2000, two articles in the New England Journal of Medi- cine (NEJM) focused on those complications. One described a Dutch study that found that, because of problems or complications, doctors in the Netherlands felt compelled to intervene (by giv- ing a lethal injection) in 18 percent of cases. This led Dr. Sherwin Nuland of Yale University to question the credibility of Oregon’s lack of re- ported complications. Nuland, who favors phy- sician-assisted suicide, noted that the Dutch have had years of practice to learn ways to overcome complications, yet complications are still re- ported. “The Dutch findings seem more credible [than the Oregon reports],” he wrote.

Deaths of Patients with Dementia Official reports do not contain a category for as-

sisted-suicide deaths of patients with dementia. Since Oregon law states that only “capable adults” (those who are able to make and communicate their health care decisions) are qualified to receive assisted suicide, it would seem that patients with dementia would not be “qualified patients.” However, there is at least one ac- count of a person with dementia dying after receiving a lethal overdose prescribed under the law: Kate Cheney, 85, died of assisted suicide under Oregon’s law even though she reportedly was suffering from early demen- tia. Her own physician declined to provide the lethal prescription. When counseling to assess her capacity was sought, a psychiatrist determined that she was not eligible for assisted suicide since she was not explicitly seeking it, and her daughter seemed to be coaching her to do so. Also, she was unable to remember the name of her doctor or details of a hospital stay that month. She was then taken to a psychologist who found that she was competent but possibly under the influence of her daughter who was “somewhat coercive.” Finally a managed care ethicist who was overseeing her case de- termined that she was qualified for assisted suicide, and the drugs were prescribed.

The tragic case of Ms. Cheney would never have come to light if her daughter had not contacted the Oregonian to express her outrage that legal safeguards had been roadblocks to her mother’s death. Within a few short years, elements of the law that had been touted as safeguards during the campaign to legalize assisted suicide were being depicted as barriers to be overcome.

Deaths of Depressed Patients Official Oregon reports contain no data regarding

the number of depressed patients who have died of phy- sician-assisted suicide. Yet, as with the case of patients with dementia, news accounts detail such deaths:

�9 The first known assisted-suicide death under the Oregon law was that of a woman in her mid-80s who had been battling breast cancer for twenty- two years. Two doctors, including her own phy- sician who believed that her request was due to depression, refitsed to prescribe the lethal drugs. Then Compassion in Dying (CID) became in- volved. Dr. Peter Goodwin, medical director of CID, determined that she was an “appropriate candidate” for death and referred her to a doctor who provided the lethal prescription. In an au- diotape, made two days before her death and played at a CID press conference, the woman said, “I will be relieved of all the stress I have.”

�9 Yet another case of a depressed patient who re- ceived the prescription for a lethal dose under Oregon’s law was described in a 2005 article in the American Journal of Psychiatry. It involved 64-year-old Michael Freeland. In 2001, Dr. Pe- ter Reagan, an assisted-suicide advocate affili- ated with CID, gave Freeland a prescription for lethal drugs under Oregon’s law. Freeland had a 43-year histou’ of acute depression and suicide attempts. However, when Freeland and his daugh- ter went to see Dr. Reagan about arranging a le- gal assisted suicide, Reagan said he didn’t think that a psychiatric consultation was necessary.

The seventh annual report indicated that only 5 per- cent of patients were referred for a psychological evalu- ation or counseling before receiving a prescription for assisted suicide. Under the assisted-suicide law, de- pressed or mentally ill patients can receive assisted sui- cide if they do not have “impaired judgment.” Con- cerning the decision to refer for a psychological evaluation, Oregon epidemiologist Dr. Mel Kohn told American Medical News, “According to the law, it’s up to the docs’ discretion.”

Requests Based on Financial ConcertLs Official reports state that six patients who died from

assisted suicide since the law went into effect may have had financial concerns. However, data about reasons for requests is based on prescribing doctors’ understand- ing of patients’ motivations. It is possible that financial concerns were much greater than reported. According to official reports, 36 percent of patients whose deaths

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were reported were on Medicare (for senior citizens) or Medicaid (for the poor). However, after the second annual report, the reports have not differentiated be- tween Medicare and Medicaid patients dying from as- sisted suicide. Oregon’s Medicaid program pays for assisted suicide but not for many other medical inter- ventions that patients need and want.

Lethal Dose More than 6 Months before Death Official reports deleted this specific category after

the second year report. Lethal prescriptions under the Oregon law are supposed to be limited to patients who have a life expectancy of six months or less. During the first two years, reports indicated that two people who had received the deadly overdose were still alive more than six months later. One patient was still alive 17 months after the lethal drugs were prescribed.

The DHS is not authorized to investigate how phy- sicians determine their patients’ diagnoses or life ex- pectancies. If physicians are prescribing for patients who do not have a terminal condition, there is no way to find out since the same doctors who are violating the guidelines would have to report their own violations. As the second annual official report stated, “[N]oncompliance is difficult to assess because of the possible repercussions for noncompliant physicians re- porting data to the division.”

Doctor-Patient Relationship Although Oregon’s assisted-suicide law requires that

at least two weeks elapse between the patient’s first and last requests for lethal drugs, the physician who actu- ally prescribes the drugs for assisted suicide need not be the same physician to whom the first request was made.

In the third through the seventh years, the doctor- patient relationship in some reported assisted-suicide cases was under one week. Thus, either some physi- cians are not complying with the two-week require- ment or they stepped in to write an assisted-suicide pre- scription after other physicians refused.

First Physician Request After the third year, official reports stopped includ-

ing the “First Physician Asked Agreed to Write Pre- scription” category. During the first three years that Oregon’s assisted-suicide law was in effect, official re- ports indicated that 41 percent of doctors to whom the first request was made refused to write a prescription for the lethal overdose. Reasons for the refusal–which could have included an assessment that the patient was not qualified or was not terminally ill–were not pro- vided.

As noted in a 2000 NEJM article, “Many patients who sought assistance with suicide had to ask more than one physician for a prescription for lethal medication.” Patients or their families can “doctor shop” until a will- ing physician is found. There is no way to know, how- ever, why the previous physicians refused to lethally prescribe (i.e., the patient was not terminally ill, had impaired judgment, etc.) since non-prescribing physi- cians are not interviewed for the official state reports. The only physicians interviewed for official reports are those who actually wrote lethal drug prescriptions for patients.

Observations on Oregon’s Official Reports As demonstrated above, Oregon’s reports leave more

questions than answers. One thing, however, is certain. Official reports contain only reported information. Therefore, it is inaccurate to state, “There have been 208 assisted-suicide deaths since Oregon’s law went into effect” or “There have been six assisted-suicide requests based on financial concerns.” It is accurate to state, “There have been 208 reported assisted-suicide deaths since Oregon’s law went into effect” or “There have been six reported assisted-suicide requests based on fi- nancial concerns.” When discussing official Oregon reports, any data should always be preceded with that all-important qualifying adjective, “reported.”

While it is not possible to know what is really taking place under Oregon’s assisted-suicide law, experiences in Belgium and the Netherlands shed some light on the unwillingness of physicians to report their activities. In September 2005, Dr. Wire Distelmans of Vrije Univcrsiteit Brussels, who serves as chair of the Fed- eral Control Commission on euthanasia, told Expatica magazine that he believes physician-assisted deaths in Belgium are as underreported as they are in the Nether- lands. According to Distelmans, who is a euthanasia supporter, the actual number of physician-assisted deaths is probably five times higher than reported. There is nothing to indicate that Oregon physicians would be any more forthcoming than their Belgian or Dutch coun- terparts.

O the r Troubling Aspects The unwillingness of many of Oregon’s physicians

to write lethal prescriptions led one HMO to issue a plea for physicians to facilitate assisted suicide and has also resulted in an assisted-suicide advocacy organization’s involvement in most assisted-suicides cases.

�9 HMO’s efforts to facilitate assisted suicide American Medical News reported on such an effort,

describing how, on August 6, 2002, Administrator Robert

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Richardson, MD, of Oregon’s Kaiser Permanente sent an e-mail to doctors affiliated with Kaiser, asking doc- tors to contact him if they were willing to act as the “attending physician” for patients requesting assisted suicide. According to the message, the HMO needed more wH~ing physician~ because “Recently our ethics service had a situation where no attending MD could be found to assist an eligible member in implementing the law for three weeks…”

Gregory Hamilton, MD, a Portland psychiatrist pointed out that the Kaiser message caused concern for several reasons. “‘This is what we’ve been worried about: Assisted suicide would be administered through HMOs and by organizations with a financial stake in provid- ing the cheapest care possible,” he said. Furthermore, despite promoters’ claims that assisted suicide would be strictly between patients and their long-time, trusted doctors, the overt recruitment of physicians to prescribe the lethal drugs indicated that those claims were not accurate. Instead, “if someone wants assisted suicide, they go to an assisted-suicide doctor–not their regular doctor.”

Kaiser’s Northwest Regional Medical Director Allan Weiland, MD, called Hamilton’s comments “ludicrous and insulting.” However, it appears that Hamilton was correct, as the involvement of an assisted-suicide advo- cacy group indicates.

�9 Assisted-suicide advocacy group involved in ma- jority of assisted-suicide deaths

If a physician opposes assisted suicide or believes the patient does not qualify under the law, Compassion in Dying (CID) has often arranged the death. At a 2003 Hemlock conference CID’s medical director said that about 75 percent of those who died using Oregon’s as- sisted-suicide law through the end of 2002 did so with CID’s assistance. And, according to data attached to its 2003 IRS Form ~:)90, CID was involved in 79 percent of such deaths during the 2003 calendar year. (Note: In early 2005, Compassion in Dying merged with the Hemlock Society and is now called Compassion and Choices.)

Lack of Family Involvement The lack of family involvement presents yet another

red flag for anyone who might be inclined to favor an Oregon-type law. Under Oregon’s law, family mem- bers do not need to be informed before a doctor helps a !oved one commit sa;,c:,de. Fam:,iy notification :,~ on!y recommended, but not required, under Oregon’s as- sisted-suicide law. The first time that a family learns that a loved one was considering suicide could be after the death has occurred.

Measures introduced in other states–including the “California Compassionate Choices Act”–have simi- larly precluded family involvement.

Protect ion for Doctors Under Oregon’s law and ir~ proposals made ia ot~ze;

states, there are greater protections tot doctors than for patients. While assisted-suicide advocates claim that patients are given new rights under Oregon’s law, noth- ing could be farther fiom the truth. Prior to the law’s passage, patients could request, but doctors could not provide, assisted suicide. It was illegal and unethical for a physician to knowingly participate in a patient’s suicide. The law actually empowers doctors by prom- ising them legal immunity if they provide a patient with an intentionally fatal prescription. Yet, advocates still say that the law grants patients a new legal right–the right to ask their doctors for suicide assistance, even though such a request was never illegal. Suicide re- quests from patients may have been cries for better pain control, support, or psychiatric help–but they were never crimes.

In addition, doctors who prescribe assisted suicide under Oregon’s law are exempt from the standard of care that they are required Io meet when providing other medical services. Under the assisted-suicide law, a health care provider !s not sub~ec’ ‘o c~mir:.a! or c;v,1 !iabi~.;.ty or any other professional disciplinary action as long as the provider is acting in “good faith.” This subjective “good faith” standard is far less stringent than the ob- jective “‘reasonable standard of care” that physicians are required to meet for compassionate medical care such as hospice, palliation, or curative treatment.

As a result, a doctor who negligently participates in assisted suicide cannot be held accountable so long as he or she claims to have acted in “good faith.” On the other hand, a doctor who negligently provides other medical intervention., can be held legally accountable in civil court regardless of his or her “good faith.” Low- ering the standard of (:are for assisted suicide could serve as an inducement for doctors to recommend assisted suicide over palliative care at the end of life.

Suicide Rate in Oregon Climbs In a touch of tragic irony, Oregon recently became

the first state to institute an elderly suicide prevention program. For years, suicide rates in western states have exceeded the national average, but the rate among older Oregonians is particuiar!y t’.igh. According to L’sa Millet of the Oregon Department of Human Services–the same governmental body responsible for issuing offi- cial reports on Oregon’s assisted-suicide law–about as many elderly Oregomans die each year from suicide as

66 SOCIETY ~ ” MAY/JUNE 2006

from car accidents. (It should be noted that deaths un- der Oregon’s assisted-suicide law are not included in suicide statistics since the cause of death is officially considered to be the person’s underlying condition.) State officials do not see any conflict between suicide prevention and support of assisted suicide, saying that the aim of the suicide prevention program is to prevent suicides among those who “still have years left to enjoy life.”

Choice or Requirement?

Oregon’s law and Oregon-style proposals in other states contain a requirement that, prior to writing a pre- scription for lethal drugs, a physician must inform the patient of alternatives such as comfort care, hospice care, and pain control. However, informing someone of an option does not mean that the patient will have the financial ability to obtain that alternative.

Devastating financial pressures could take place in a state like California if it were to legalize physician- assisted suicide. Bear in mind that there were six re- ported assisted-suicide deaths in Oregon because of fi- nancial concerns. Then consider the fact that the number of Californians who went without health insurance in 2002 was almost double Oregon’s entire state popula- tion.

As was so tragically apparent during hurricane Katrina, not everyone who was “informed” of evacua- tion routes had the resources to use those routes. Like- wise, patients without health insurance or with inad- equate health insurance may not be able to pay for the pain control that would help them. While assisted sui- cide may be a choice for the comfortably well off, it could become the only “medical treatment” that the poor can afford.

When Oregon’s assisted-suicide law passed in 1994, assisted-suicide activists thought other states would quickly fall in line. Through 2005, rather than sweep- ing the field as they expected, the assisted-suicide move-

ment has been stopped cold–in the courts, at the ballot box, and in legislatures. Each time they predicted vic- tory. Every year they spent massive amounts of money so that another state could join Oregon in permitting assisted suicide. They have, thus far, been unsuccess- ful. But it would be dangerous to believe that they have been stopped permanently. They are dedicated and com- mitted. They are not about to give up. If anything, they are forging ahead with greater resolve.

In the September/October 2005 edition of Foreign Policy, Princeton bioethics professor Peter Singer, who advocates infanticide, euthanasia, and bestiality, pre- dicted that, by 2040, the traditional view of the sanc- tity of human life will be considered indefensible and will be held by “only a rump of hard-core, know-noth- ing religious fundamentalists.” According to Singer, a new ethic will acknowledge that personhood depends upon self-awareness and euthanasia will be viewed as a human right. Singer’s prediction could come true, but it is not inevitable.

The debate over assisted suicide and euthanasia will continue to be waged at the ballot box, in legislatures, in courts of law, in the court of public opinion and, tragically, in churches across the country. Its impor- tance merits not only meticulous examination, but also the commitment and dedication of all who seek to pro- tect individuals, families, and society. Each and every person who respects human life must become involved in maintaining the barriers against assisted suicide and euthanasia. The stakes could not be higher.

Rita L. Marker is an attorney and executive director of the International Task Force on Euthanasia and Assisted Sui- cide. She is the author of Deadly Compassion. The present article is adapted from “The Future of Euthanasia” in The Religion & Society Report. Additional, documented infi)rmation about assisted suicide and euthanasia is avail- able at the International Task Force website (www.internationaltaskforce.org).

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