Euthanasia, Assisted Suicide & Health Care Decisions

Euthanasia, Assisted Suicide & Health Care Decisions:
Protecting Yourself & Your Family

The words "euthanasia" and "assisted suicide" are often used interchangeably. However, they are different and, in the law, they are treated differently. In this report, "euthanasia" is defined as intentionally, knowingly and directly acting to cause the death of another person (e.g., giving a lethal injection). "Assisted suicide" is defined as intentionally, knowingly and directly providing the means of death to another person so that the person can use that means to commit suicide (e.g., providing a prescription for a lethal dose of drugs).

Part I of this report discusses the reasons used by activists to promote changes in the law; the contradictions that the actual proposals have with those reasons; and the logical progression that occurs when euthanasia and assisted suicide are transformed into medical treatments. It explores the failure of so-called safeguards and outlines the impact that euthanasia and assisted suicide have on families and society in general.

Withholding and withdrawing medical treatment and care are not legally considered euthanasia or assisted suicide. Withholding or withdrawing food and fluids is considered acceptable removal of a "medical treatment."

Part II of this report includes information about practical ways to protect oneself and loved ones during any time of incapacity and a discussion of some of the policies that have led to patients being denied care that they or their decision-makers have requested. It concludes with an examination of the ethical distinction between treatment and care.

PART I

EUTHANASIA & ASSISTED SUICIDE

MOVING THE BOUNDARIES

In 2002, the International Task Force report, "Assisted Suicide: Not for Adults Only?" (1) discussed euthanasia and assisted suicide for children and teens. At that time, such concerns were largely considered outside the realm of possibility.

Then, as now, assisted-suicide advocates claimed that they were only trying to offer compassionate options for competent, terminally ill adults who were suffering unbearably. By and large, their claims went unchallenged.

A crack in that carefully honed image appeared in 2004 when the "Groningen Protocol" elicited worldwide outrage. The primary purpose of that protocol – formulated by doctors at the Groningen Academic Hospital in the Netherlands – was to legally and professionally protect Dutch doctors who kill severely disabled newborns. (2)

While euthanasia for infants (infanticide) was not new, widespread discussion of it was. Dutch doctors were now explaining that it was a necessary part of pediatric care.

Also in 2004, Holland's most prestigious medical society (KNMG) urged the Health Ministry to set up a board to review euthanasia for people who had "no free will," including children and individuals with mental retardation or severe brain damage following accidents. (3)

At first, it seemed that these revelations would be harmful to the euthanasia movement, but the opposite was true.

Why?

Awareness of infanticide and euthanasia deaths of other incompetent patients moved the boundaries.

Prior to the widespread realization that involuntary euthanasia was taking place, advocacy of assisted suicide for those who request it seemed to be on one end of the spectrum. Opposition to it was on the other end.

Now, the practice of involuntary euthanasia took its place as one extreme, opposition to it as the other extreme, and assisted suicide for terminally ill competent adults appeared to be in the "moderate middle" – a very advantageous political position – and expansion of the practice to others had entered the realm of respectable debate.

This repositioning has become a tool in the assisted-suicide arsenal. In May 2006, an assisted-suicide bill, patterned after Oregon's law permitting assisted suicide, failed to gain approval in the British Parliament. The bill's supporters immediately declared that they would reintroduce it during the next parliamentary session.

Within two weeks, Professor Len Doyal – a former member of the British Medical Association's ethics committee who is considered one of England's leading experts on medical ethics – called for doctors to be able to end the lives of some patients "swiftly, humanely and without guilt," even without the patient's consent. (4) Doyal's proposal was widely reported and, undoubtedly, when the next assisted-suicide bill is introduced in England, a measure that would permit assisted suicide only for consenting adults will appear less radical than it might have seemed prior to Doyal's suggestion.

Currently, euthanasia is a medical treatment in the Netherlands and Belgium. Assisted suicide is a medical treatment in the Netherlands, Belgium and Oregon. Their advocates erroneously portray both practices as personal, private acts. However, legalization is not about the private and the personal. It is about public policy, and it affects ethics, medicine, law, families and children.

A FAMILY AFFAIR

In December 2005, ABC News' World News Tonight reported, "Anita and Frank go often to the burial place of their daughter Chanou.... Chanou died when, with her parents' consent, doctors gave her a lethal dose of morphine.... 'I'm convinced that if we meet again somewhere in heaven,' her father said, 'she'll tell us we reached the most perfect solution.'"(5)

The report about the six-month-old Dutch child's death was introduced as a report on the "debate over euthanizing infants." A Dutch legislator who agrees that doctors who intentionally end their tiny patients' lives should not be prosecuted said, "I'm certainly pro-life. But I'm also a human being. I think when there is extreme, unbearable suffering, then there can be extreme relief." (6)

Gone was the previous year's outrage over the Groningen Protocols. Infanticide had entered the realm of respectable debate in the mainstream media. The message given to viewers was that loving parents, compassionate doctors and caring legislators favor infanticide. It left the impression that opposing such a death would be cold, unfeeling and, perhaps, intentionally cruel.

In Oregon, some assisted-suicide deaths have become family or social events.

Oregon's law does not require family members to know that a loved one is planning to commit suicide with a doctor's help. (7) Thus, the first knowledge of those plans could come when a family member finds the body. However, as two news features illustrate, some Oregonians who die from assisted suicide make it a teachable moment for children or a party event for friends and family.

According to the Mail Tribune (Medford, Oregon), on a sunny afternoon, Joan Lucas rode around looking at houses, then she sat in a park eating an ice cream cone. A few hours later, she committed suicide with a prescribed deadly drug overdose. "Grandchildren were made to understand that Grandma Joan would be going away soon. Those who were old enough to understand were told what was happening." (8)

Did these children learn from Grandma Joan that suicide is a good thing?

UCLA's student newspaper, the Daily Bruin, carried an article favoring assisted suicide. It described how Karen Janoch who committed suicide under the Oregon law, sent invitations for her suicide to about two dozen of her closest friends and family. The invitation read, "You are invited to attend the actual ending of my life." (9) At the same time California's legislature was considering an assisted-suicide bill that was virtually identical to Oregon's law, UCLA students learned that suicide can be the occasion for a party.

In Oregon, assisted suicide has gone from the appalling to the appealing, from the tragic to the banal.

During the last half of 2005 and the first half of 2006, bills to legalize assisted suicide were under consideration in various states and countries including, but not limited to, Canada, Great Britain, California, Hawaii, Vermont, and Washington. All had met failure by the end of June 2006. But plans to reintroduce them with some cosmetic changes are currently underway. A brief examination of arguments used to promote them illustrates the "small world" nature of assisted-suicide advocacy.

TWO PILLARS OF ADVOCACY

Wherever an assisted-suicide measure is proposed, proponents' arguments and strategies are similar. Invariably, promotion rests on two pillars: autonomy and the elimination of suffering.

Autonomy

Autonomy (independence and the right of self-determination) is certainly valued in modern society and patients do, and should, have the right to accept or reject medical treatment. However, those who favor assisted suicide claim that autonomy extends to the right of a patient to decide when, where, how and why to die as the following examples illustrate.

During debate over an assisted-suicide measure then pending before the British Parliament, proponents emphasized personal choice. The bill, titled "The Assisted Dying for the Terminally Ill Bill," was introduced by Lord Joel Joffe. Dr. Margaret Branthwaite, a physician, barrister and former head of England's Voluntary Euthanasia Society (recently renamed Dignity in Dying (10)), called for passage of the Joffe bill in an article in the British Medical Journal. "As a matter of principle," she wrote, "it reinforces current trends towards greater respect for personal autonomy." (11)

The focus on autonomy was also reflected in remarks about a plan to introduce an assisted-suicide initiative in Washington. Booth Gardner, former governor of Washington, said he plans to promote the initiative because it should be his decision when and how he dies. He told the Seattle Post-Intelligencer, "When I go, I want to decide." (12)

The rationale is that when, where, why and how one dies should be a matter of self-determination, a matter of independent choice, and a matter of personal autonomy.
Elimination of suffering

The second pillar of assisted-suicide advocacy is elimination of suffering. During each and every attempt to permit euthanasia and assisted suicide, its advocates stress that ending suffering justifies legalization of the practices.

California Assemblywoman Patty Berg, the co-sponsor of California's euphemistically named "Compassionate Choices Act," (13) said the assisted-suicide measure was necessary so that people would have the comfort of knowing "they could escape unbearable suffering if that were to occur." (14)

In an opinion piece supporting the failed 1998 assisted-suicide initiative in Michigan, a spokesperson for those favoring the measure wrote that the patients "targeted" by the proposal were those who were "tortured by the unbearable suffering of a slow and agonizing death." (15)

In the United Kingdom, Lord Joffe said his bill would enable those who are "suffering unbearably" to get medical assistance to die. (16) Testimony before the British House of Lords Select Committee studying the bill noted that, where "assisted dying" has been legalized, it has done so "as a response to patients who were suffering." (17)

The centerpiece of the 1994 Measure 16 campaign that resulted in Oregon's assisted-suicide law was a television commercial featuring Patti Rosen. Describing her daughter who had cancer, Rosen said, "The pain was so great that she couldn't bear to be touched.... Measure 16 would have allowed my daughter to die with dignity." (18)

When an assisted-suicide proposal that later failed was being considered by the Hawaiian legislature in 2002, a public relations consultant who was working on behalf of the bill, e-mailed a template for use in written or oral testimony. The template suggested inclusion of the phrases "agonizingly painful," "pain was uncontrollable," and "pain beyond my understanding." (19)

During consideration of an assisted-suicide bill in Vermont, the state's former governor Philip Hoff said, "The last thing I would want in this world is to be around and be in pain, and have no quality of life, and be a burden to my family and others." (20) Dick Walters, chairman of Death with Dignity Vermont, said the proposal would permit a person to "peacefully end suffering and hasten death." (21)

Thus, the rationale given by euthanasia and assisted-suicide proponents for legalization always includes autonomy and/or elimination of suffering. However, the laws they propose actually contradict this rationale.

CONTRADICTIONS

When proposed, laws such as those now in existence in Oregon and similar measures introduced elsewhere include conditions or requirements limiting assisted suicide to certain groups of "qualified patients." A patient qualified to receive the treatment of assisted suicide must be an adult who is capable of making decisions and must be diagnosed with a terminal condition.

If one accepts the premise that assisted suicide is a good medical treatment that should be permitted on the basis of personal autonomy or elimination of suffering, other questions must be raised.

If the reason for permitting assisted suicide is autonomy, why should assisted suicide be limited to the terminally ill?
Does one's autonomy depend upon a doctor's diagnosis (or misdiagnosis) of a terminal illness? If a person is not terminally ill, but is suffering – whether physically, psychologically or emotionally – why isn't it up to that person to decide when, why and how to die? Does a person only have autonomy if he or she has a particular condition or illness? Is autonomy a basis for the law?

If assisted suicide is a good and acceptable medical treatment for the purpose of ending suffering, why should it be limited to adults who are capable of decision-making?
Isn't it both discriminatory and cruel to deny that good and acceptable medical treatment to a child or an incompetent adult? Why is a medical treatment that has been deemed appropriate to end suffering available to an 18-year-old, but not to a 16-year-old or 17-year-old? Why is a person only eligible to have his or her suffering ended if he or she has reached an arbitrary age?

And, what of the adult who never was, or no longer is, capable of decision-making? Should that person be denied medical treatment that ends suffering? Are euthanasia and assisted-suicide laws based on the need to eliminate suffering, or not?

Establishing arbitrary requirements that must be met prior to qualifying for the medical treatment of euthanasia or assisted suicide does, without doubt, contradict the two pillars on which justification for the practices is based.

The question then must be asked: Why are those arbitrary requirements included in Oregon's law and other similar proposals? The answer is simple. After a series of defeats, euthanasia and assisted-suicide proponents learned that they had to propose laws that appeared palatable.

In April 2005, Lord Joffe, the British bill's sponsor, acknowledged that his bill was intended to be only the first step. During hearings regarding the measure, he said that "this is the first stage" and went on to explain that "one should go forward in incremental stages. I believe that this bill should initially be limited...." (22)

He repeated his remarks a year later when discussing hearings about his bill. "I can assure you that I would prefer that the [proposed] law did apply to patients who were younger and who were not terminally ill but who were suffering unbearable," he said and added, "I believe that this bill should initially be limited." (23)

STEP-BY-STEP APPROACH

Proposals for euthanasia and assisted suicide have always emanated from advocacy groups, not from any grassroots desire. Those groups learned that attempting to go too far, too fast, leads to certain defeat.

After many failed attempts, most recently those in the early 90s in Washington and California – when ballot initiatives that would have permitted both euthanasia by lethal injection and assisted suicide by lethal prescription were resoundingly defeated – "death with dignity" activists changed their strategy. They decided to take a step-by-step approach, proposing an assisted-suicide-only bill which, when passed, would serve as a model for subsequent laws. Only after several such laws were passed, would they begin to expand them. That was the strategy that led to Oregon's Measure 16, the "Oregon Death with Dignity Act."

Those who were most involved in the successful Oregon strategy were not new to the scene.

Cheryl K. Smith, who wrote the first draft of Oregon's law, had served as a special counsel to the political action group Oregon Right to Die (ORD). Smith had been the National Hemlock Society’s legal advisor after her graduation from law school in 1989 and had been a top aide to Hemlock's co-founder, Derek Humphry. While a student at the University of Iowa College of Law, Smith helped draft a "Model Aid-in-Dying Act" that provided for children’s lives to be terminated either at their own request or, if under 6 years of age, by parental request. (24)

Barbara Coombs Lee was Measure 16’s chief petitioner. At the time, she was a vice president for a large Oregon managed care program. After the law's passage, she took over the leadership of Compassion in Dying. (25) [Note: In early 2005, Compassion in Dying merged with the Hemlock Society. The combined organization is now called Compassion and Choices.]

Coombs Lee’s promotion of assisted suicide and euthanasia began prior to her involvement with the Death with Dignity Act. As a legislative aide to Oregon Senator Frank Roberts in 1991, she worked on Senate Bill 114 that would have permitted euthanasia on request of a patient and, if the patient was not competent, a designated representative would have been authorized to request the patient’s death. (26)

Upon passage of the Oregon law in 1994, many assisted-suicide supporters were certain that other states would immediately fall in line. However, that did not occur. Between 1994 and mid-2006, assisted-suicide measures were introduced in state after state.(27) Each and every proposal failed. All of the proposals were assisted-suicide-only bills and, with one exception, (28) every one was virtually identical to the Oregon law.

Among supporters of assisted suicide and euthanasia, though, the Oregon law is seen as the model for success and is referred to in debates about assisted suicide throughout the world. For that reason, a careful examination of the Oregon experience is vital to understanding the problems with legalized assisted suicide.

OREGON

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. (29)

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 patients have died from physician-assisted suicide. Statistics from official reports are particularly questionable and have left some observers skeptical about their validity.

For example, when a similar proposal was under consideration in the British Parliament, members of a House of Lords Committee traveled to Oregon seeking information regarding Oregon's law for use in their deliberations. The public and press were not present during the closed-door hearings. However, the House of Lords published the committee's proceedings in three lengthy volumes, which included the exact wording of questions and answers.

After hearing witnesses claim that there have been no complications associated with more than 200 assisted-suicide deaths, committee member Lord McColl of Dulwich, a surgeon, said, "If any surgeon or physician had told me that he did 200 procedures without any complications, I knew that he possibly needed counseling and had no insight. We come here and I am told there are no complications. There is something strange going on." (30)

The following includes statistical data from official reports and other published information dealing with troubling aspects of the practice of assisted suicide in Oregon. Statements from the 744-page second volume of the House of Lords committee proceedings are also included. None of the included statements from the committee hearings were made by opponents of Oregon's law.

OFFICIAL REPORTS

Assisted-suicide deaths reported during the first eight years

Official Reports: 246
Actual Number: Unknown

The latest annual report indicates that reported assisted-suicide deaths have increased by more than 230% since the first year of legal assisted suicide in Oregon. (31) The numbers, however, could be far greater. From the time the law went into effect, Oregon officials in charge of formulating annual reports have conceded "there’s no way to know if additional deaths went unreported" because Oregon DHS "has no regulatory authority or resources to ensure compliance with the law." (32)

The DHS has to rely on the word of doctors who prescribe the lethal drugs. (33) Referring to physicians’ reports, the reporting division admitted: "For that matter the entire account [received from a prescribing doctor] could have been a cock-and-bull story. We assume, however, that physicians were their usual careful and accurate selves." (34)

The Death with Dignity law contains no penalties for doctors who do not report prescribing lethal doses for the purpose of suicide.

Complications occurring during assisted suicide

Official Reports: 13 (12 instances of vomiting & one patient who did not die from
lethal dose.)
Actual number: Unknown

Prescribing doctors may not know about all complications since, over the course of eight years, physicians who prescribed the lethal drugs for assisted suicide were present at only 19.5% of reported deaths. (35) Information they provide might come from secondhand accounts of those present at the deaths (36) or may be based on guesswork.

When asked if there is any systematic way of finding out and recording complications, Dr. Katrina Hedberg who was a lead author of most of Oregon's official reports said, "Not other than asking physicians." (37) She acknowledged that "after they write the prescription, the physician may not keep track of the patient." (38) Dr. Melvin Kohn, a lead author of the eighth annual report, noted that, in every case that they hear about, "it is the self-report, if you will, of the physician involved." (39)

Complications contained in news reports are not included in official reports

Patrick Matheny received his lethal prescription from Oregon Health Science University 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." (40) The annual report did not make note of this situation.

Speaking 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...." (41)
Overdoses of barbiturates are known to cause vomiting as a person begins to lose consciousness. The patient then inhales the vomit. In other cases, panic, feelings of terror and assaultive behavior can occur from the drug-induced confusion. (42) But Barrett would not say exactly which symptoms had taken place in this instance. She has refused any further discussion of the case.

Complications are not investigated

David Prueitt took the prescribed lethal dose in the presence of his family and members of Compassion & Choices. After being unconscious for 65 hours, he awoke. It was only after his family told the media about the botched assisted suicide that Compassion & Choices publicly acknowledged the case. (43) DHS issued a release saying it "has no authority to investigate individual Death with Dignity cases." (44)

Referring to DHS's ability to look into complications, Dr. Hedberg explained that "we are not given the resources to investigate" and "not only do we not have the resources to do it, but we do not have any legal authority to insert ourselves." (45)

David Hopkins, Data Analyst for the Eighth Annual Report, said, "We do not report to the Board of Medical Examiners if complications occur; no, it is not required by law and it is not part of our duty." (46)

Jim Kronenberg, the Oregon Medical Associations' (OMA) Chief Operating Officer, explained that "the way the law is set up there is really no way to determine that [complications occurred] unless there is some kind of disaster." "[P]ersonally I have never had a report where there was a true disaster," he said. "Certainly that does not mean that you should infer there has not been, I just do not know." (47)

In the Netherlands, assisted-suicide complications and problems are not uncommon. One Dutch study found that, because of problems or complications, doctors in the Netherlands felt compelled to intervene (by giving a lethal injection) in 18% of cases.(48)

This led Dr. Sherwin Nuland of Yale University School of Medicine to question the credibility of Oregon’s lack of reported complications. Nuland, who favors physician-assisted suicide, noted that the Dutch have had years of practice to learn ways to overcome complications, yet complications are still reported. "The Dutch findings seem more credible [than the Oregon reports]," he wrote. (49)

Assisted-suicide deaths of patients with impaired judgment

Official Reports: 0 (Official reports do not contain this category.)
Actual number: Unknown

Under the assisted-suicide law, depressed or mentally ill patients can receive assisted suicide if they do not have "impaired judgment." (50) Concerning the decision to refer for a psychological evaluation, Dr. Kohn said, "According to the law, it’s up to the docs’ discretion." (51) During the last year for which reports are available, only 5% of patients were referred for a psychological evaluation or counseling before receiving a prescription for assisted suicide. (52)

Even if a patient is competent when the prescription is written, that may not be the case when the lethal drugs are taken. Dr. Hedberg acknowledged that there is no assessment of patients after the prescribing is completed. "Our job is to make sure that all the steps happened up to the point the prescription was written," (53) she said. "In fact, after they write the prescription, the physician may not keep track of that patient.... [T]he law itself only provides for writing the prescription, not what happens afterwards." (54)

Kate Cheney, 85, died of assisted suicide under Oregon’s law even though she reportedly was suffering from early dementia. Her own physician declined to provide the lethal prescription. When counseling to determine 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. She was then taken to a psychologist who determined 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 determined that she was qualified for assisted suicide and the drugs were prescribed. (55)

Assisted-suicide deaths of depressed patients

Official Reports: 0 (Official reports do not contain this category.)
Actual number: Unknown

The first known assisted-suicide death under the Oregon law was that of a woman in her mid-eighties who had been battling breast cancer for twenty-two years. Two doctors, including her own physician who believed that her request was due to depression, refused to prescribe the lethal drugs. Then Compassion in Dying (CID), now called Compassion and Choices, became involved. Dr. Peter Goodwin, who was then the medical director of CID, (56) determined that she was an "appropriate candidate" for death and referred her to a doctor who provided the lethal prescription. In an audiotape, 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." (57)

In 2001, Dr. Peter Reagan, an assisted-suicide advocate affiliated with CID, gave Michael Freeland a prescription for lethal drugs under Oregon’s law. Freeland, 64, had a 43-year history of acute depression and suicide attempts. However, when Freeland and his daughter went to see Dr. Reagan about arranging a legal assisted suicide, Dr. Reagan said he didn’t think that a psychiatric consultation was "necessary." (58)

Assisted-suicide requests based on financial concerns

Official Reports: 7
Actual number: Unknown

Data about reasons for requests is based on prescribing doctors’ understanding of patients’ motivations. It is possible that financial concerns were much greater than reported. According to official reports, 36.5% of patients whose deaths were reported were on Medicare (for senior citizens) or Medicaid (for the poor) and an additional 1% had no insurance. (59)

After the second annual report, official reports have not differentiated between Medicare and Medicaid patients dying from assisted suicide.

Patients who received lethal dose more than 6 months before death

Official Reports: 2 or 4 (After the 2nd year, official reports stopped including this category.)
Actual number: Unknown

Lethal prescriptions under Oregon's law are supposed to be limited to patients who have a life expectancy of six months or less. (60)

One patient was still alive 17 months after the lethal drugs were prescribed, (61) and, during the first two years of the law’s implementation, at least one lethal dose was prescribed more than eight months before the patient took it. (62) The DHS is not authorized to investigate how physicians determine their patients’ diagnoses or life expectancies. (63)

According to the OMA's Chief Operating Officer, Jim Kronenberg, most physicians have told him that trying to predict that a patient has less than six months to live "is a stretch." "Two hours, a day, yes, but six months is difficult to do," he explained. (64)

Dr. Peter Rasmussen, an advisory board member of the Oregon chapter of C & C, (65) has been involved in Oregon assisted-suicide deaths numbering in double digits. He said life expectancy predictions for a person entering the final phase of life are inaccurate. He dismissed this as unimportant, saying, "Admittedly, we are inaccurate in prognosticating the time of death under those circumstances, we can easily be 100 percent off, but I do not think that is a problem. If we say a patient has six months to live and we are off by 100 percent and it is really three months or even twelve months, I do not think the patient is harmed in any way…." (66)

Shortest length of time reported for prescribing doctor-patient relationship

Official Reports: Less than one week
Actual Number: Unknown

Oregon’s assisted-suicide law requires that at least two weeks elapse between the patient’s first and last requests for lethal drugs. (67) Yet, for the third through the eighth years, the doctor-patient relationship in some reported assisted-suicide cases was under one week. (68) Thus, official reports indicate that either some physicians are not complying with the two-week requirement or they step in to write an assisted-suicide prescription after other physicians refused.

First physician asked agreed to write prescription

Official Reports: 27 (41%) in the first three years. (After the 3rd year, official reports stopped including this category.)
Actual number: Unknown

A New England Journal of Medicine article noted that "many patients who sought assistance with suicide had to ask more than one physician for a prescription for lethal medication." (69) Patients or their families can "doctor shop" until a willing physician is found.

There is no way to know, however, why the previous physicians refused to lethally prescribe (i.e., the patient was not terminally ill, had impaired judgment, etc.) since non-prescribing physicians 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. (70)

OTHER TROUBLING ASPECTS of ASSISTED SUICIDE in OREGON

No way to track the drugs once they are received

"[W]e do not have a way to track if there was a big bottle [of lethal drugs] sitting in somebody's medicine cabinet and they died whether or not somebody else chose to use
it," explained Dr. Hedberg. (71)

Self-administration is very broadly interpreted

Dr. Rasmussen explained that, in one case, he opened 90 capsules – a lethal dose – of barbiturates and poured the white powder into a bowl of chocolate pudding. He gave the mixture to the woman's son who spooned the mixture into his mother's mouth. Another son gave her sips of water to wash the solution down. The woman died twelve hours later. (72) (Because the woman performed the last action – swallowing – that led to her death, the act was technically assisted suicide, not euthanasia.)

According to Sue Davidson of the Oregon Nurses Association (ONA), a 2002 survey found that nurses were very actively involved in the process and that "some indicated that they had assisted [patients] in the taking of it [the lethal dose]." (73)

Lethal drugs do not need to be taken orally

Barbara Glidewell who educates Oregon Health & Science University (OHSU) patients and their families about "the need for a dying plan and to rehearse the plan" (74) said that patients who cannot swallow would "need to have an NG tube or G tube placement." (75) Then, they could "express the medication through a large bore syringe that would go into their G tube." (76)

Oregon's 2005 Guidebook for Health Care Professionals states, "It remains unclear whether the Oregon Death with Dignity Act allows an attending physician to prescribe an injectable drug for the patient to self-administer for the purpose of ending life." (77)

Discussing a case in which a man said he helped his brother-in-law take the prescribed drugs, Dr. Hedberg said, "[W]e do not know exactly how he helped this person swallow, whether it was putting a feed tube down or whatever, but he was not prosecuted...." (78)

"Safeguards" are disregarded but no one is disciplined

Referring to assisted-suicide cases that were in violation of the law – where only one of the required two witnesses signed the request or where doctors prescribed the lethal drugs without waiting for 15 days as the law requires – Dr. Hedberg said, "[T]here have been a number over the years." (79)

Kathleen Haley, Executive Director of the Oregon Board of Medical Examiners, said four such cases, one involving multiple patients, (80) were reported to the Board of Medical Examiners. This resulted in issuance of two "letters of concern" that are considered "letters of advice." She explained that the letters "are not public and they are not official disciplinary actions." (81)

Records used in annual reports are destroyed

Dr. Hedberg said, "After we issue the annual report, we destroy the records." (82) Thus, there is no way to track if the same physicians have violated the law during more than one year.

HMOs are facilitating assisted suicide

The unwillingness of many physicians to write lethal prescriptions led one HMO to issue a plea for physicians to facilitate assisted suicide.

On August 6, 2002, Administrator Robert Richardson, MD, of Oregon’s Kaiser Permanente sent an e-mail to doctors affiliated with Kaiser, asking doctors 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 willing physicians 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...." (83)
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 providing 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." (84)

Kaiser’s Northwest Regional Medical Director Allan Weiland, MD, called Dr. Hamilton’s comments "ludicrous and insulting." (85) But it appears that Dr. Hamilton was correct, as the involvement of an assisted-suicide advocacy group indicates.

Assisted-suicide advocacy group facilitates most of Oregon's assisted suicides

If a physician opposes assisted suicide or believes the patient does not qualify under the law, C & C or its predecessor organizations has often arranged the death.

Dr. Peter Goodwin, the group's former medical director said that about 75% of those who died using Oregon’s assisted-suicide law through the end of 2002 did so with the organization's assistance. (86)

During the 2003 calendar year, the organization was involved in 79% of assisted-suicide deaths. (87)

According to Dr. Elizabeth Goy of OHSU, Compassion in Dying (now called Compassion and Choices (88)) sees "almost 90 percent of requesting Oregonians...." (89)

Barbara Farmer of the Visiting Nurses Association said, if a person's own doctor doesn't want to participate, "we have advised them to work with Compassion in Dying...." (90)

The state pays for assisted-suicide drugs for the poor

Oregon’s Medicaid program pays for assisted suicide (91) but not for many other medical interventions that patients need and want.

Ann Jackson, Executive Director and primary spokesperson of the Oregon Hospice Association, explained, "The State of Oregon, under the Oregon Health Plan, will buy the medications.... The drugs are very inexpensive." (92)

No family notification required before a doctor helps a loved one commit suicide

Family notification is only recommended, but not required, under Oregon’s assisted-suicide law. (93) The first time that a family learns that a loved one was considering suicide could be after the death has occurred.

Prescribing doctors decide what "residency" means

Under Oregon's law, a patient must be a resident of Oregon. Residence can be demonstrated by means that include, but are not limited to, a driver's license or a voter registration. (94)

According to Dr. Hedberg, "It is up to the doctor to decide" whether the person is a resident. There is no time element during which one must have lived in Oregon. "If somebody really wanted to participate, they could move from their home state," she said. "I do not think it happens very much...." (95)

Pain control has become increasingly inadequate in Oregon

As of 2004, nurses reported that the inadequacy of meeting patients' pain needs had increased "up to 50 percent even though the emphasis on pain management has remained the same or is slightly more vigorous.... Most of the small hospitals in the state do not have pain consultation teams at all," said a spokesperson for the Oregon Nurses Association. (96)
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As other states and countries consider Oregon-type laws, it remains to be seen whether decision-makers will rely on the deceptively rosy picture painted by assisted-suicide supporters – or on the reality of the Oregon experience.

OPPOSING EUTHANASIA & ASSISTED SUICIDE EFFORTS

It is important to be concerned about assisted suicide and euthanasia. But concern alone doesn't protect anyone. Tragically, some people worry about the dangers and assume that either there is nothing they can do or that they don't have the time to get involved in effectively opposing those seeking death on demand.

There is, however, much that can be done by everyone, no matter what one's age, occupation or financial ability may be. The following are some concrete suggestions.

As already discussed, assisted-suicide laws have been and will continue to be proposed throughout the country, using two prime avenues – ballot initiatives and legislative proposals.

No matter which of those two avenues may be taken, effective advocacy of one's position can include the following:

Be informed. Nothing destroys credibility more than having the facts wrong. Be able to cite your source for any information.

Keep to the issue. There are many other "hot button" issues that one may feel passionate about. But, when discussing assisted suicide, keep the focus on assisted suicide. Don't be sidetracked to other issues. Don't be tempted to compare assisted suicide to other issues.

Write letters to the editor of your local newspaper. Keep the letters short and to the point. (The "Letters to the Editor" section of any newspaper is one of the most-read sections, only behind the sports page and advice columns.)

Always ask yourself three questions:
1. Who am I trying to reach? Know your "audience." Is it a neighbor, family member, legislator, large gathering or general reader of the local newspaper?

2. What am I trying to accomplish? Specifically, what is my one goal in saying or writing this?

3. Will what I am planning to say or write reach the person or persons I'm attempting to reach and will it accomplish what I'm trying to accomplish?

Recognize that your views are important. Your personal views, shared with clarity and respect, can have a far greater impact on those you know than anything an outside "expert" may say.

Become involved. Be active in neighborhood, community, professional, church and/or political activities if possible. If you are already taking part in such activities, you will have far greater influence when speaking about assisted suicide because you will have established relationships. People will know you as a friend and colleague.

Don't take anyone's viewpoint for granted. When the issue is assisted suicide, one cannot predict another's stance on the topic based on political or religious affiliations, nor can one's view regarding assisted suicide be predicted based on a position related to other issues such as abortion, capital punishment, etc.

Legislative proposals

If an assisted-suicide measure is proposed in the state legislature, the best thing to do is to elect lawmakers who share your viewpoint about assisted suicide. This means finding out where candidates stand on the issue. If you are pleased with the position taken by a candidate, donate to the campaign or volunteer to work on the campaign, even if it is only to make a few phone calls on the candidate's behalf.

Then, continue to maintain contact with your elected officials after they get into office. If you have established some type of relationship with your elected official or with his or her staff, it is far more likely that your voice will be heard when a really important issue comes up.

If an assisted-suicide measure is pending, don't wait until it is almost time for a vote to contact your elected official. Generally, by the time a measure gets to a vote, minds are made up. This is not to say that testifying at hearings about a measure is useless, but it is far easier to change minds before that point.

Remember that short personal letters are far more effective than petitions or form letters. Some suggestions:

Keep letters short (ideally one page long). A multi-page, single spaced letter filled with underlining shouts, "Ignore me." That type of letter may get a form letter in response, but it's only effect will be to alert office staff to ignore the next letter or message from the sender.

Be accurate. Make sure you can back up everything you write.

Say "thank you." Occasionally send a letter thanking your elected official for a particular position or vote that he/she has taken.

Be respectful but firm. Recognize that a lawmaker may, at first, favor a particular proposal that you know is dangerous. His or her intent may be good. But that good intent will not protect people from the sometimes deadly content of a measure. Gently point out the problems in the bill. Be clear, concise, brief, and respectful.

Use correct terminology. Remember the definitions of euthanasia and assisted suicide explained at the beginning of this report.

Note: The ITF is not a lobbying organization so it does not contact legislators seeking to influence their votes. However, the ITF does analyze pending assisted-suicide bills. A selected point from such an analysis can be used in a letter or message to a lawmaker. Remember, you – as someone who votes for the lawmaker – will have far more influence on an elected official than any outside organization or expert.

Voter initiative or referendum

If a proposal will be decided by a direct vote of the people, either through a referendum or an initiative, the voters – you, your friends, family, neighbors and colleagues – will be deciding whether the crime of assisted suicide will become a "medical treatment" in your state.

There are many effective ways to help others understand the danger of such a proposal. The following ideas are only a few such ways:

Before such a measure is actually scheduled for the ballot, begin to discuss assisted suicide with others.

If you are a member of a church, professional or civic organization, become involved in the program committee. If you have suggested other speakers who have been interesting, your suggestion to schedule a speaker who will discuss assisted suicide is more likely to be accepted. (You may even decide that you will offer to be the speaker for the topic.)

If you belong to an organization that frequently or occasionally adopts resolutions supporting or opposing pending legislation, draft a simple resolution supporting your position on assisted suicide. Line up support for it among others in the organization before proposing it. If your resolution passes, make certain that your organization issues a press release announcing the resolution.

.....

Assisted suicide and euthanasia do, indeed, pose a great threat to families and to all of society. But, with the exception of Oregon, the Netherlands and Belgium, attempts to legalize them have been unsuccessful.

Unfortunately, there are other threats to vulnerable individuals. Those threats and the ways to protect oneself and one's loved ones are addressed in Part II of this report.

Endnotes for Part I:

1. Some portions of Assisted Suicide: Not for Adults Only? are included in this report. For entire text, see Not for Adults Only.

2. "20 October 2004, Pediatricians and child neurologists of the Groningen Academic Hospital find that in very extraordinary cases doctors must have the possibility of ending the life of young children.... Groningen pediatricians in the past years have developed a protocol that can serve as a guideline in cases of the active ending of life. The protocol serves as guarantee for careful action and makes the manner of work of the medical treatment team transparent and testable." English translation from "Protocol waarborgt zorgvuldigheid bij levenseinde kind" 29 October 2004, accessed at: http://www.azg.nl/azg/nl/nieuwa/persberichten/43604.

3. Toby Sterling, "Netherlands hospital says it has euthanized 4 gravely ill babies," San Francisco Chronicle, Dec. 1, 2004.

4. "'Legalise euthanasia' says expert," BBC News, June 8, 2006.

5. "Baby Euthanasia," ABC News' World News Tonight Transcript, Dec. 4, 2005.

6. Ibid.

7. Family notification is only recommended, but not required, under Oregon's assisted-suicide law. ORS 127.835 §3.05.

8. Bill Kettler, "Family lives through emotions of mother's assisted suicide," Mail Tribune (Medford, OR), July 7, 2000.

9. Jason O'Bryan, "Right to die must be legalized, protected," The Daily Bruin Online, Jan. 20, 2006.

10. The new name was approved by the VES in 2005 and went into effect in January 2006. The British organization followed the lead of U.S. and Australian euthanasia and assisted-suicide groups that have also changed their names to portray a more appealing image. For more information on the name changes.

11. M.A. Branthwaite, "Time for change," British Medical Journal, vol. 331 (Sept. 24, 2005), p. 681.