Oregon’s Dying With
Dignity Act allows for medical practitioners to prescribe drugs for
self-administration by a person to allow the person to end his or her life.
Oregon publishes annual reports on the operation of the Dying With Dignity Act. A careful analysis of this data reveals
significant issues with the practice of physician assisted suicide in Oregon.
The data for 2017 - the twentieth year of legal assisted suicide in Oregon - was released on 9 February 2018.
The data shows that concern about "being a burden on family, friends/caregivers" (55.2%) is a far more frequent reason for obtaining a lethal substance to commit suicide than is concern about pain control (21%).
It also shows that non-terminal illnesses such as diabetes and arthritis are being accepted as justifying assisted suicide.
Physical
suffering not a major issue – “being a burden” is
The Oregon annual reports indicate that physical suffering is
not a major issue for those requesting physician assisted suicide.
Of the 1275 people who had died from ingesting a lethal dose
of medication as of 19 January 2018 just over one in four (25.8%) mentioned “inadequate pain control or concern about it”
as a consideration. Only
30 out of the 143 (21%) who died from ingesting a lethal dose of medication in
2017 mentioned a concern about pain control.
Earlier annual reports noted that “Patients discussing concern about inadequate pain control with their
physicians were not necessarily experiencing pain.”
However, in 2017 more one out of two people (55.2%) who died
after taking prescribed lethal medication cited concerns about being a “Burden on family, friends/caregivers” as
a reason for the request.
Physician assisted suicide has much more to do with
relieving other people of a “burden”
than relieving unbearable pain.
To facilitate and fund euthanasia and assisted suicide of
persons simply because feel they are a burden on family, friends or caregivers
sends a cruel message to the elderly, disabled or chronically ill who may need
the care and support of others in order to function in daily life. It implies
that only the strong and fully independent have the right to live.
Mental
health: No adequate screening
Research by Linda Ganzini has established that one in six
people who died under Oregon’s law had clinical depression.
Depression is supposed to be screened for under the Act. However, in 2017 only 5 out of 143 people
(3.5%) who died under the Oregon law were referred by the prescribing doctor
for a psychiatric evaluation before writing a script for a lethal substance.
In 2011 Dr. Charles J. Bentz of the Division of General
Medicine and Geriatrics at Oregon Health & Sciences University explained that Oregon's physician-assisted suicide law is not working well. He cited the example of a 76-year-old patient
he referred to a cancer specialist for evaluation and therapy. The patient was a keen hiker and as he
underwent therapy, he became depressed partly because he was less able to
engage in hiking.
He expressed a wish for assisted suicide to the cancer
specialist, who rather than making any effort to deal with the patient’s
depression, proceeded to act on this request by asking Dr Bentz to be the
second concurring physician to the patient’s request.
When Dr Bentz declined and proposed that instead the
patient’s depression should be addressed the cancer specialist simply found a
more compliant doctor for a second opinion.
Two weeks later the patient was dead from a lethal overdose
prescribed under the Act.
Dr Bentz concludes “In
most jurisdictions, suicidal ideation is interpreted as a cry for help. In Oregon, the only help my patient got was a
lethal prescription intended to kill him.”
He urges other jurisdictions “Don't
make Oregon's mistake.”
Financial
considerations
Of those who died from ingesting a lethal dose of medication
in 2017, more than one in twenty (5.6%) mentioned the “financial implications of treatment” as a consideration. While this
percentage is relatively small it is appalling that since 1998 forty seven (47)
Oregonians have died from a lethal prescription after expressing concerns about
the financial implications of treatment.
In two notorious cases, those of Barbara Wagner and RandyStroup, the Oregon Health Plan informed a patient by letter that the particular
cancer treatment recommended by their physicians was not covered by the Plan
but that the cost of a lethal prescription to end their life would be covered.
The
misleading notion of a peaceful death
Euthanasia and assisted suicide proponents hold out the
promise of a peaceful death by fast acting lethal substances. The lethal drugs most likely to be preferred
by medical practitioners have been secobarbital and pentobarbital. As of 19 January 2018 secobarbital had been
used in 58.6% of cases and pentobarbital in 30.3% of cases in Oregon.
Pentobarbital is no longer available in the United States and the price of
secobarbital has increased significantly so physicians have been experimenting
with various lethal cocktails. In Oregon in 2017 nearly half (46.2%) of all
deaths by ingesting a lethal dose involved a cocktail in which morphine sulfate
was the main lethal substance.
These drugs do not always result in a swift and peaceful
death.
In 2017 more than one in nine (11.63%) of those for whom
information about the circumstances of their deaths is available either had
difficulty ingesting or regurgitated the lethal dose, had seizures or other complications
or regained consciousness and died subsequently from the underlying illness.
The interval from ingestion of lethal drugs to
unconsciousness has been as long as four hours (in 2017) while the time from
ingestion to death has been as 104 hours (4 days and 8 hours). One person in
2017 took 21 hours to die.
In 2005, “One patient became unconscious 25 minutes after
ingestion, then regained consciousness 65 hours later. This person did not
obtain a subsequent prescription, and died 14 days later of the underlying
illness (17 days after ingesting the medication).
This patient was lumberjack David Prueitt who, after
ingesting the prescribed barbiturates spent three days in a deep coma, then
suddenly woke up, asking his wife “Honey,
what the hell happened? Why am I not dead?” David survived for another 14 days before dying naturally
from his cancer.
Since 2005 six other people have regained consciousness
after ingesting the lethal medication.
“In 2010, two patients
regained consciousness after ingesting medications. One patient
regained consciousness 88 hours after ingesting the medication, subsequently
dying from underlying illness three months later. The other patient
regained consciousness within 24 hours, subsequently dying from underlying
illness five days following ingestion.
In 2011, two patients
regained consciousness after ingesting the medication. One of the patients very
briefly regained consciousness after ingesting the prescribed medication and
died from underlying illness about 30 hours later. The other patient regained
consciousness approximately 14 hours after ingesting the medication and died
from underlying illness about 38 hours later.”
In 2012 “one patient
ingested the medication but regained consciousness before dying of underlying
illness ... The patient regained
consciousness two days following ingestion, but remained minimally responsive
and died six days following ingestion”.
In 2017 “one patient
ingested the medication but regained consciousness before dying from the
underlying illness”.
Increase in number of deaths
The number of deaths from ingesting lethal substances
prescribed under Oregon’s Death With
Dignity Act reached 143 in 2017 (up 3.6% from 2016, and nearly triple the 49 deaths in 2007) continuing
a steady rise since 1998, the first year of the Act’s operation when 16 people
died under its provisions.
Faulty
prognosis
The Death With Dignity
Act provides that before prescribing a lethal substance a doctor must first
determine whether a person has a “terminal disease”. This is defined by section 127.800 (12) of
the Oregon Revised Statute to mean “an incurable and irreversible
disease that has been medically confirmed and will, within reasonable medical
judgment, produce death within six months”.
In 2017 one person ingested lethal medication 603 days
(nearly 20 months) after the initial request for the lethal prescription was
made. The longest duration between
initial request and ingestion recorded is 1009 days (that is 2 years and 9
months). Evidently in these cases the
prognosis was wildly inaccurate.
Dr
Kenneth Stevens has written about his experience of how the prognosis of six
months to live works in practice under Oregon’s law:
Oregon’s assisted-suicide law applies to patients predicted to have
less than six months to live. In 2000, I
had a cancer patient named Jeanette Hall.
Another doctor had given her a terminal diagnosis of six months to a
year to live. This was based on her not
being treated for cancer.
At our first meeting, Jeanette told me that she did not want to be
treated, and that she wanted to opt for what our law allowed – to kill herself
with a lethal dose of barbiturates.
I did not and do not believe in assisted suicide. I informed her that her cancer was treatable
and that her prospects were good. But
she wanted “the pills.” She had made up her mind, but she continued to see me.
On the third or fourth visit, I asked her about her family and learned
that she had a son. I asked her how he
would feel if she went through with her plan.
Shortly after that, she agreed to be treated, and her cancer was cured.
Five years later she saw me in a restaurant and said, “Dr. Stevens, you
saved my life!”
For her, the mere presence of legal assisted suicide had steered her to
suicide.
Not a terminal illness
Oregon’s Death With Dignity Act requires that a person be
certified by two physicians as suffering from a terminal illness before a
lethal dose of medication can be lawfully prescribed.
The 2016 Annual Report listed conditions that have been accepted
as meeting this definition including besides malignant neoplasms (i.e. cancers)
and amyotrophic lateral sclerosis, heart disease, chronic lower respiratory
disease, HIV/AIDS, benign and
uncertain neoplasms, other respiratory diseases, diseases of the nervous
system (including multiple sclerosis, Parkinson’s disease and Huntington’s
disease), musculoskeletal and connective tissue diseases, viral hepatitis, diabetes
mellitus, cerebrovascular disease, and alcoholic liver disease.
Earlier annual reports specifically mention some
diseases that would not normally be classified as a terminal illness:
●
myelodyoplastic
syndrome (not terminal unless it develops into acute myeloid leukemia which itself is
not necessarily terminal) (2003 Annual Report, p. 19);
●
Hepatitis C (2004 Annual Report , p. 21)
●
digestive organ neoplasm of unknown behavior! (2004 Annual
Report , p. 21)
●
cardiomyopathy (may cause death but not necessarily
terminal) (2006 Annual Report, p. 5)
●
endocarditis (not usually considered a terminal illness,
only 20% mortality rate during initial infection) (2006, Annual Report, p. 5).
The 2017 annualreport reveals that there have been a total of 8 people for whom the “underlying
illness” has been listed as “Endocrine/metabolic disease [e.g.,
diabetes]”. It also cites arthritis, arteritis, stenosis and sclerosis (none of
which are usually terminal illnesses) as the underlying illness in at least one
case each.
This suggests that even the requirement that an illness be terminal is not being strictly applied.
It has been confirmed by theOregon Health Authority that if a person with a chronic illness, such as
diabetes, foregoes treatment such as insulin injections, for any reason (including
financial reasons or suicidal ideation) and thereby is likely to die within six
months, the person becomes eligible for assisted suicide.
The Oregon Health Authority has also clarified that all information about a person’s underlying illness is simply
based on reports by the physician who prescribes the lethal medication and a second
consulting physician. There is no independent checking of the veracity of those
reports.
A burden on the family: a recipe for elder abuse
The data from Oregon shows that in
2017 more one out of two (55.2%) people who died after taking prescribed lethal
medication cited concerns about being a “Burden
on family, friends/caregivers” as a reason for the request.
Does the concern about being a
burden originate from the person or is it generated by subtle or not so subtle
messages from family, friends and caregivers - including physicians - who find
the person to be a burden or a nuisance or just taking too long to die?
Elder law expert Margaret Dore comments:
In both Washington and Oregon, the official
reporting forms include a check-the-box question with seven possible
"concerns" that contributed to the lethal dose request. These
concerns include the patient's feeling that he was a "burden."
The prescribing doctor is instructed:
"Please check 'yes,' 'no,' or 'don't know' depending on whether or not you
believe that a concern contributed to the request."
In
other states, a person being described as a "burden" is a warning
sign of abuse. For example, Sarah Scott of Idaho Adult Protection Services
describes the following "warning sign": "Suspect behavior by
the caregiver . . . [d]escribes the vulnerable adult as a burden or nuisance."
The recommendation is that when such
"warning signs" exist, a report should be made to law enforcement
and/or to the local adult protective services provider.
Washington and Oregon, by contrast, instruct
its doctors to check a "burden" box. Washington and Oregon promote
the idea that its citizens are burdens, which justifies the prescription of
lethal drugs to kill them. Washington's and Oregon's Acts do not promote
patient "control," but officially sanctioned abuse of vulnerable
adults.
Short relationship with attending
physicians
The
Oregon statute specifies that lethal prescriptions only be written by a
person’s “attending physician” who is
defined as “the physician who has primary
responsibility for the care of the patient and treatment of the patient's
terminal disease.”
The data
indicates that in some cases doctors have had a relationship with the patient of
less than one week’s duration and that in 2017, in half the cases the doctor-patient
relationship was of 10 weeks duration or less.
A total of 92 physicians wrote 218 prescriptions during 2017
(1‐29 prescriptions per physician).
Taken
together this data suggests that there are some doctors in Oregon very willing
to write prescriptions for lethal substances for patients they barely know. One
doctor in 2017 was writing a prescription for a lethal dose more frequently
than once a fortnight (29 times in a year).
Who administers the lethal
medication?
In 2017 either the prescribing physician (16.78%) or another
healthcare provider (16.78%) was known to be present at the time the lethal
medication was ingested. For the remaining two out of three (66.43%) people
there was no physician or other healthcare provider known to be present at the
time of ingestion.
In other words for two out of three
cases there is no independent evidence that the person took the lethal
medication voluntarily. It may well have been administered to them by a
family member or other person under duress, surreptitiously or violently. We
can never know.
Increase in
suicide rate
Proponents have claimed that legalising physician assisted
suicide would actually prevent, or at least delay, suicides by giving those
faced with a terminal illness an assurance that the means for obtaining peaceful death was legally available.
However, a study of comparative rates of suicide in US states found that for
the states, like Oregon and Washington, which had legalised physician assisted
suicide there is an increase in the overall suicide rate of 6.3% compared to
all other states and of the suicide rate of those aged 65 and over of 14.5%.
There is no reduction in either the rate of non-assisted suicides or in the
mean age of suicide.
