Reno reverses DEA ruling
United States Attorney General Janet Reno has decided that Oregon’s Death with Dignity Act (DWDA), the new assisted-suicide law permitting doctors to write lethal drug prescriptions, does not violate federal law. Furthermore, according to Reno, the federal Controlled Substances Act (CSA) does not authorize the U.S. Department of Justice, through the U.S. Drug Enforcement Administration (DEA), to take any “adverse action” against physicians who intentionally prescribe fatal doses of controlled drugs under the provisions of the Oregon law.
Reno’s ruling overturns an earlier determination issued by DEA Administrator Thomas A. Constantine that the Oregon law would violate the Controlled Substances Act, which authorizes the DEA to revoke the prescribing license of any physician dispensing controlled drugs without a “legitimate medical purpose.” According to Constantine, assistance in suicide does not constitute such a legitimate goal. Supporters of the Oregon law objected to Constantine’s conclusions and called for a review of the matter by Reno. (See Updates, 11-12/97:4, 1-3/98:5.)
Reno’s determination came in the form of a letter to Rep. Henry Hyde, chairman of the House Judiciary Committee and who, along with Sen. Orrin Hatch, had requested Constantine’s assessment of the Oregon law. “The Department has reviewed the issue thoroughly,” Reno wrote, “and has concluded that adverse action against a physician who has assisted in a suicide in full compliance with the Oregon Act would not be authorized by the CSA.” “There is no evidence,” Reno concluded, “that Congress, in the CSA, intended to displace the states as the primary regulators of the medical profession, or to override a state’s determination as to what constitutes legitimate medical practice in the absence of a federal law prohibiting that practice.” [J. Reno, Letter to Henry Hyde, 6/5/98, pp. 1, 3. Hereafter cited as “Letter.”]
Ruling flawed
Those in Oregon who argue in support of the assisted-suicide law agree with Reno’s conclusions. Oregon Attorney General Hardy Myers said last year that the state’s voters determined that assisted suicide is a legitimate medical practice, and the DEA has no authority to counter that. [Oregonian, 11/20/97]
However, that is not the same conclusion federal authorities reached when California voters passed an initiative allowing the use of marijuana for medicinal purposes, including pain control. In fact, just last March, lawyers from Reno’s Justice Dept. told U.S. District Court Judge Charles Breyer that the California law, passed in 1996, violated the federal Controlled Substance Act. “What this case is about, make no mistake about it, is upholding federal law,” argued Mark Quinlivan, a Justice Dept. attorney. “A state initiative cannot supplant the will of the people of the United States,” he said. [Reuters, 3/25/98] In his ruling, Judge Breyer sided with the federal government and ordered all the California cannabis clubs to stop selling marijuana. He wrote, “A state law which purports to legalize the distribution of marijuana for any purpose…even a laudable one, nonetheless directly conflicts with federal law.” [San Francisco Chronicle, 5/15/98]
To shore up her contention that Congress never intended the Controlled Substance Act to apply to a duly-passed state law such as Oregon’s, Reno claimed that Congress intended the scope of the CSA to be somewhat limited, and authorized the DEA to prevent the “particular drug abuse”; deriving from a drug’s “stimulant, depressant, or hallucinogenic effect on the central nervous system.”; [Letter, p. 3; emphasis added]
But, if that is so, then her argument actually supports Constantine’s original determination that the CSA does authorize DEA action against doctors who comply with the assisted-suicide law. At the recommendation of euthanasia “experts” (like Dutch physicians Pieter Admiraal and Gerrit Kimsma), the drugs of choice under the Oregon law are barbiturates in lethal overdoses. (See Update, 8-10/97:1.) Barbiturates work precisely by depressing the central nervous system. That is why they are often legitimately prescribed to control anxiety and sleep disturbances. To prescribe or take these drugs in intentional overdoses would constitute drug abuse in every state in the country–even in Oregon, unless, according to Reno, the patient is deemed qualified for death under the assisted-suicide law. It would seem then that Reno’s ruling only adds to the already discriminatory nature of the Oregon law, singling out those patients thought to be terminally ill and denying them the same protections against the type of drug abuse Congress intended the CSA and the DEA to provide for everyone else.
“Adverse action under the CSA,” Reno wrote to Hyde, “may well be warranted in other circumstances: for example, where a physician assists in a suicide in a state that has not authorized the practice under any conditions, or where a physician fails to comply with the state procedures in doing so. However, the federal government’s pursuit of adverse actions against Oregon physicians who fully comply with that state’s Death with Dignity Act would be beyond the purpose of the CSA.” [Letter, p. 4]
A week after she issued her ruling, Reno told reporters that the Oregon law does not violate the civil rights of terminally-ill patients who want to die, but added that there is a risk of abuse. “I think the federal government has got to continue to make sure that (the Oregon law) is not used in a way that would deprive somebody of their civil rights or create situations such as that,” she said. “And the important thing is that the law, as it has been written in Oregon, doesn’t create a problem of that nature,” she added. [Oregonian, 6/12/98]
Reno did not elaborate on exactly how the federal government was going to “make sure” patients’ rights are not violated. And given the provisions contained in the DWDA, that will be far easier said than done.
Law restricts oversight
Because Reno has declared Oregon a safe zone for assisted-suicide doctors, it is expected that there will be an increase in the number of lethal prescriptions dispensed. So far, there have been four assisted deaths reported in the media. The actual number of deaths and the circumstances, however, may never be known, since the law has been implemented in such a way as to keep information regarding the deaths private and away from public scrutiny. (See Update, 11-12/97:3.)
All information which the public received regarding the first reported deaths was channeled through right-to-die groups (Compassion in Dying and Hemlock Society), the doctor who assisted the death, or some “anonymous” newspaper source. What little information was released, was generally spun in such a way as to depict a peaceful, loving death, and advance the euthanasia agenda.
Few media members, if any, questioned, for example, Compassion in Dying medical director Dr. Peter Goodwin’s account of one woman’s experience prior to her assisted death. According to Goodwin, two other physicians had declined to help bring on her death. One had diagnosed the woman, who had breast cancer, as being depressed. He said her depression was causing her to want to die. But Goodwin dismissed that diagnosis as “questionable,” and sent her to a doctor sympathetic to the assisted-suicide cause. [Oregonian, 3/26/98] So, instead of getting a prescription or other help for her treatable depression, this woman was referred to a doctor who gave her a prescription for death.
The provisions of the Oregon law were specifically written to privatize induced deaths. In fact, the law bars even the Oregon State Health Division from reviewing all but a “sample” of the deaths, and even that limited information, according to the law, “shall not be a public record and may not be made available for inspection by the public.” [DWDA, 1994, Section 3.11] Margot White, a lawyer and bioethicist studying the DWDA, explained, “What’s happening here is… an atmosphere where privacy is protected to such a degree that there is almost a gag order mentality on who has access to information.” [Oregonian, 5/10/98]
But, is protecting privacy (including the doctor’s) more important than protecting the patient? At least for now, Reno’s ruling makes it clear that, while doctors are protected, it’s the patient who has been abandoned on both the state and federal levels.
Bill to Ban Assisted Suicide Introduced in Congress
Within hours of U.S. Attorney General Janet Reno’s ruling that Oregon’s assisted-suicide law does not violate federal law, Rep. Henry J. Hyde (R-Illinois) and Rep. James L. Oberstar (D-Minnesota) co-sponsored the House version of a bill which amends the federal Controlled Substance Act to specifically prohibit physician-assisted suicide. Commenting on Reno’s decision, Hyde, the chairman of the House Judiciary Committee and an opponent of the Oregon law, said, “I just think she’s mistaken, her interpretation.” [Oregonian, 6/6/98]
According to Hyde, the bill banning assisted suicide “reaffirms that physicians should use federally regulated drugs for legitimate medical goals such as relief of pain and suffering, and denies a physician the necessary federal license to prescribe such drugs to provide lethal doses for assisted suicides.” “This law ensures that no federal program or health facility will ever be complicit in the practice of helping to cause patients’ death,” he said. [Rep. H. Hyde, Press Release, 6/5/98]
The bill, entitled “Lethal Drug Abuse Prevention Act of 1998,” appears to have support. A Senate version, introduced by Assistant Majority Leader Don Nickles (R-Oklahoma), already has 15 co-sponsors, and Oregon’s own Sen. Gordon Smith (R) has indicated that he will support it. However, another Oregon senator, Ron Wyden (D), said he personally voted against the assisted-suicide law, but since the measure was passed by the state’s voters, Congress should support it. [Oregonian, 6/12/98]
According to The Oregonian, the state’s largest newspaper, more than 200 members of Congress wrote to Reno prior to her ruling, urging her to uphold the DEA’s authority to revoke the prescribing privileges of Oregon physicians who provide patients with lethal medications. “So far,” the newspaper reported, “opposition seems to outweigh congressional support for assisted suicide.” [Oregonian, 6/6/98]
The national pro-euthanasia group Hemlock Society USA issued a press statement following the introduction of Hyde’s bill. “Hemlock executive director Faye Girsh said neither Congress nor any federal agency should be allowed to interfere with what is essentially a matter of states rights,” the statement read. [Hemlock USA Press Release, 6/6/98]
But, according to a letter sent to Reno last April, signed by House Speaker Newt Gingrich, House Majority Leader Dick Armey, House Majority Whip Tom DeLay and 50 other congressional members, “A decision by a state to rescind its own penalties for assisting a suicide cannot supersede federal laws, compel federal support or remove federal responsibility to uniformly enforce laws passed by Congress and approved by the president.” [Oregonian, 4/3/98]
Assisted Suicide Battle Heats Up in Michigan
The debate over assisted suicide is intensifying in Michigan. No longer does the issue revolve simply around assisted-suicide advocate Jack Kevorkian, his associates, and the corpses they generate, then abandon. Now it looks like Michigan’s voters will have to face the issue at the polls in November, and determine if killing will become accepted public policy and accepted medical practice in that state.
Merian’s Friends submits initiative signatures
Despite reported financial and other difficulties, the assisted-suicide group Merian’s Friends has met the 5/27/98 deadline, submitting, they say, 379,000 voter signatures to qualify their assisted-suicide initiative for the 11/3/98 ballot. The group – named for Merian Frederick, a 72-year-old Ann Arbor woman whose life was ended in 1993 with Kevorkian’s help – only needed to obtain 247,000 valid signatures. [Detroit News, 5/27/98] Currently, efforts are underway to scrutinize the submitted initiative petitions to verify that the signatures contained on each one are truly valid.
The proposed, lengthy initiative, entitled “Terminally Ill Patient’s Right to End Unbearable Pain or Suffering,” would make it legal in Michigan for doctors to intentionally prescribe lethal medications for the purpose of ending certain patients’ lives. While some of the measure’s provisions are similar to those contained in Oregon’s assisted-suicide law (Measure 16), most others differ significantly. For example, the Michigan measure adds a definition of “medication” that would specifically allow the administration of lethal medication(s) through a “nasogastric or gastrostomy tube” to patients who cannot swallow. [“Terminally Ill Patient’s Right to End Unbearable Pain or Suffering,” Sec. 5673(I)] No such provision is contained in the Oregon law.
Hemlock Society USA executive director Faye Girsh has said that Hemlock’s legislative arm, Patients’ Rights Organization (PRO-USA), “will support the Michigan effort wholeheartedly.” Girsh called the initiative “a carefully crafted piece of legislation which has excellent safeguards” and said that it is “a tribute to Merian Frederick who made a choice about how she wanted to die.” “It is a right,” Girsh added, “which should be granted to all Americans.” [Hemlock Society USA Press Release, 5/27/98]
But Kevorkian attorney Geoffrey Fieger said, during an interview on public television’s Off the Record, that the assisted-suicide measure Girsh claims has “excellent safeguards” can’t really be regulated. “For instance,” he said, “this law, Merian’s Friends’ law, proposes a six-month terminal rule. That’s phony. There isn’t a doctor or a medical school in the country that teaches you whether somebody’s six minutes, six years or six days terminal. How are you going to enforce that? That’s a phony regulation.” A Detroit News editorial on Fieger’s assessment of the initiative concluded:
“[Fieger] should know all about the impossibility of ‘regulating’ assisted suicide. After all, Dr. Kevorkian, early in his crusade, proclaimed that his ‘patients’ went through a careful screening process. Yet Dr. Kevorkian’s roster of patients includes Frank Long, treated for decades for mental illness. Dead. Judith Curren, who was improperly given anti-depression drugs by her own husband. Dead. And Rebecca Badger, whose diagnosis of multiple sclerosis was a mistake. Dead. Geoffrey Fieger is absolutely right. ‘You can’t really regulate’ assisted suicide.” [Editorial, Detroit News, 4/25/98]
Opposition mounts
Many Michigan doctors are vehemently opposed to the initiative. Advocates for Better Care (ABC), a grassroots network of physicians, formally voiced its opposition when Merian’s Friends submitted its signatures “As physicians, we know that patients generally consider suicide out of desperation. That’s disturbing to us because we know such fear and desperation is unnecessary. We have the means to give patients dignity and comfort without killing them,” explained Dr. Tom George, an anesthesiologist and hospice medical director in Kalamazoo, MI.
“Both statewide physicians’ organizations (Michigan State Medical Society and Michigan Osteopathic Association) have formal positions opposed to legalizing physician-assisted suicide,” said Dr. Louis R. Zako, ABC member and past president of the Medical Society. “As individual physicians, we are appealing to our colleagues to speak out in defense of our vulnerable patients and the integrity of our profession,” he added. “Doctors ought not be singled out as society’s executioners.” [ABC Press Release, 5/26/98]
The Michigan Hospice Organization (MHO) has reaffirmed its firm opposition to assisted suicide as well. In a strongly worded statement, MHO stated that “assisted suicide is not a component of hospice care.” “To encourage an early end to one’s life by creating a law that would legalize assisted suicide is to take a giant step backward regarding the care of the terminally ill in Michigan.” According to MHO, “Dame Cicely Saunders provided the philosophy that still permeates hospice today: ‘…we will do all that we can…to help you live until you die.’ There is no room for assisted suicide in that statement.” [MHO Press Release, 5/27/98]
New coalitions have been formed to help people dealing with end-of-life situations and to steer them away from assisted suicide. The coalitions – which include organizations such as the MI Department of Community Health, MI State Medical Society, MI Hospice Organization, MI Catholic Conference, and Right to Life of MI – hope to promote hospice care, pain and symptom management, as well as address other end-of-life concerns and problems facing patients, families, and doctors. [Detroit News, 4/25/98, 6/6/98] Another coalition, consisting of eight Jewish, Christian, and Muslim leaders, has issued an interfaith letter opposing assisted suicide. “Our shared traditions,” the leaders wrote, “speak against the use of physician-assisted suicide as an acceptable means of confronting end-of-life decision making.” [Detroit Free Press, 5/7/98]
Hemlock Society helps launch campaign as Not Dead Yet protests
In an effort to draw attention to the Merian’s Friends’ initiative, the Hemlock Society USA held its annual national conference in Ann Arbor, June 5-7, 1998. But, instead of reporters focusing on the possible campaign, most of the media exposure dealt with protestors from the disability rights group Not Dead Yet (NDY) and their warning that legalization of assisted suicide and euthanasia would profoundly threaten the lives of disabled persons.
“Hemlock is lobbying actively in many states to enact, by legislation or referendum, a radical change in legal and social policy, a policy that will result in massive pressures on ill and disabled people to take the cheapest way out – the ‘Final Exit’ solution,” explained NDY founder Diane Coleman. “We’re not paranoid, as Hemlock wants you to believe,” said Steve Drake, the group’s Internet coordinator. “Many people with nonterminal disabilities have already died in the name of the so-called right-to-die movement, including the majority of Kevorkian’s victims.” [NDY Press Release, 6/6/98]
On the second day of the conference, about 50 NDY members, many in wheelchairs, occupied the Sheraton Inn’s lobby, disrupting the Hemlock meeting. When they refused to move to an area which had been designated for the protest, eight were arrested for trespassing, while 12 were cited for blocking the hotel’s doorways and creating a fire hazard. [Ann Arbor News, 6/7/98; Detroit Free Press, 6/7/98]
One focus of NDY’s protest was a policy statement issued by Hemlock executive director Faye Girsh last December. In that statement, Girsh called for the creation of very lenient penalties for “mercy killings” involving people whose lives are considered to be “too burdensome.” (See Update 1-3/98:1.) “As far as we are concerned,” said Carol Cleigh, a disability rights advocate from Illinois, “Hemlock, Kevorkian and his attorney are partners in crime.” [NDY Press Release, 6/4/98] “Basically, this is legalized killing of anybody with any type of disability,” said Tom Cagle from New Hampshire. Taped to his motorized wheelchair was a sign saying, “With friends like Merian’s, who needs enemies?” [Detroit News, 6/6/98]
Poll Shows Support for Assisted Suicide Slipping
In a recent press release, Merian’s Friends spokesman Dr. Edward Pierce stated, “Polls show that Michigan voters favor Physician Aid in Dying almost two to one – 59 percent in favor and only 33 percent opposed.” [MF Press Release, 5/26/98]
But a poll conducted by the Detroit News during the last week of May found that only 44% of Michigan’s likely voters favor the assisted suicide initiative, 39% oppose it, and nearly 20% haven’t made up their minds yet.
Steve Mitchell, the East Lansing pollster who conducted the poll for the newspaper, said that supporters of the measure have “an uphill fight.” “At this point, I’d say it’s unlikely this will pass. Even though it has a slight lead right now, undecided voters tend to vote ‘no’ on ballot measures.” “You really need to start with 60 to 65 (percent of support) to ensure victory,” he explained.
The poll, which has a ±5% error margin, found that women are more likely to oppose assisted suicide than men. Of the women surveyed, 38% support the initiative, 47% oppose it, with 15% undecided. Among male voters, 51% favor the measure, 30% oppose it, and 19% are undecided. [Detroit News, 5/31/98]
As reported in the last Update [1-3/98:8], the drop in support in Michigan was also observed by another pollster, Ed Sarpolus, who said last March, “Our tracking over the last several years shows support has waned from the mid-60s down to the mid-50s….” [Detroit News, 3/13/98]
Kevorkian Adds Kidney Harvesting to Assisted Suicide Agenda
Reminiscent of a scene out of a “mad scientist” movie, a “team” comprised of Jack Kevorkian and his associates removed the kidneys of 45-year-old Joseph Tushkowski, from Las Vegas, NV, who was paralyzed from the neck down as a result of a hunting accident 21 years ago. According to Oakland County (MI) Medical Examiner L.J. Dragovic, Tushkowski’s kidneys were “chopped” out after he died of poison from an intravenous injection. The death was ruled a homicide. [UPI, 6/8/98]
Tushkowski’s sister, a nurse in Nevada, had suspected that her brother was considering suicide after she intercepted a call from Kevorkian, but told her brother, “…you do what you feel like you have to do.” [Las Vegas Review-Journal, 6/8/98] Kevorkian lawyer Michael Schwartz told reporters that Tushkowski “wanted to save somebody else’s life.” Kevorkian insisted that the kidneys were removed according to “standard protocol” in a sterile environment, but refused to elaborate on where and how the surgery took place. The organs, Kevorkian said, had been removed at 11am on 6/7/98, and would be good for transplantation for 36 hours. Interested parties were told to call the law offices of Fieger, Fieger, and Schwartz. Kevorkian added, “The odds of this [the kidneys] being used are nil.” “No so-called legitimate medical outfit will touch it,” he said. [Detroit Free Press, 6/8/98; UPI, 6/7/98; AP, 6/7/98]
On the last point, Kevorkian was correct. No reputable transplant team or hospital wanted the organs because of serious concerns regarding strict protocols for contamination and donor screening. According to Dr. Robert Merian, chief of the transplantation program at the University of Michigan, “Dr. Kevorkian methods are inappropriate and unacceptable.” [Detroit Free Press, 6/8/98] But it was not until the autopsy findings were reported that it became apparent just how “inappropriate and unacceptable” Kevorkian’s handling of the organ retrieval really was. Oakland County Medical Examiner L.J. Dragovic, who performed the autopsy, told reporters, “I don’t want to insult people who work in slaughterhouses, but this looked like it was done there.” The autopsy showed that Tushkowski’s body was “mutilated.”
“They didn’t remove his sweater. They just pulled it up, then cut the belly,” Dragovic explained. “This is not a situation to be compared with the highly skilled act of organ procurement surgery… we’re talking about a chopped-up body.” Not even the entry incision was done professionally. Instead of the usual straight incision from the breastbone to the navel, Tushkowski had a crooked 11-inch vertical cut and two other horizontal incisions. According to Dragovic, cut arteries were not tied off correctly. Normally arteries are clamped off and sutured or stapled closed. Kevorkian’s team took “back yard twine,” the kind “used to hang clothes on,” to do the job. [Detroit News, 6/9/98] “I wouldn’t even try to compare it to anything professional,” Dragovic told a Las Vegas paper. “Any professional work entails inherent responsibilities and purpose. This had no purpose whatsoever and there is no responsibility built into this whole act.” [Las Vegas Review-Journal, 6/9/98] “Everyone knows that once a person is dead, the organs are no good,” Dragovic said. [Detroit Free Press, 6/9/98]
Michigan law stipulates that if a vital organ is removed after death – in an operation not part of a postmortem exam or embalming – such action constitutes “mutilation,” a felony punishable by up to 10 years in prison. [MCL 750 160] Oakland County Prosecutor Dave Gorcyca, who has refused to prosecute Kevorkian for assisted suicides under common law, claims that because Kevorkian, his associates, and Tushkowski’s family are not talking, no charges can be filed. “We can all assume what may have occurred,” Gorcyca told the media, “but we can’t prove it in a court of law.” [AP, 6/9/98]
But Michael Modelski, a former Oakland County assistant prosecutor, countered that claim. “Even if Mr. Gorcyca has resolved to not enforce the common law ban against assisted suicide, it does not follow that Kevorkian should be allowed a blank check to violate other Michigan laws he finds inconvenient,” Modelski explained. “The Michigan Legislature together with the Governor have given prosecutors the power of investigative subpoenas….Where witnesses refuse to cooperate or to answer questions, they can be given immunity and compelled to testify.” [M. Modelski, Letter to the Editor, Detroit News, written 6/9/98]
One place where Kevorkian and his assistant, Dr. Georges Reding, might be held accountable is in Royal Oak, where Jim Marcinkowski, the deputy assistant city attorney, has vowed to take them to court, charging them with obstructing a police officer and resisting arrest. The misdemeanor charges stem from an altercation with police officers on 5/7/98 when Kevorkian and Reding were attempting to drop off the body of Matthew Johnson, a depressed and despairing 26-year-old who was left quadriplegic after a motorcycle accident in California last year. The scuffle occurred outside of a Royal Oak hospital, where witnesses said Kevorkian and Reding were pushing and shoving the police. Both men were arrested, and held overnight. They were later released on personal bond, but a pretrial hearing has been set for June 15. Each charge carries a maximum sentence of 90 days and a $500 fine. [AP, 6/2/98; San Jose Mercury News, 5/10/98; Oakland Press, 5/9/98; Detroit News, 5/8/98]
As a result of the Royal Oak charges, the Oakland County gun board unanimously voted on 6/2/98 to suspend Kevorkian’s license to carry a concealed gun. Kevorkian attended the hearing to protest the suspension. [Detroit Free Press, 6/3/98]
Latest Kevorkian Victims
Mary Judith Kanner
67, from MI,
died 3/26/98,
Huntington’s disease
Shala Semino
46, from AZ,
died 4/8/98,
ALS
Dixie Coleen Wilson
64, from MO,
died 4/13/98,
ALS
Priscilla Hiles
73, from CA,
died 4/17/98,
arthritis, asthma, sciatica
Jack Schenbern
89, from FL,
died 4/17/98,
prostate cancer
Lucille Alderman
86, from MI,
died 4/24/98,
heart condition, degenerative joint condition,
only victim to die from cyanide
Matthew Johnson
26, from CA,
died 5/7/98,
quadriplegia
Emma Kassa
68, from OH,
died 5/19/98,
lung cancer
Joseph Tushkowski
45, from NV,
died 6/7/98,
quadriplegia
kidneys harvested
Research in Review
Doctors surveyed on induced deaths
A recent national survey, published in the New England Journal of Medicine, found that 6.4% of responding physicians had “acceded to at least one request for assistance with suicide or a lethal injection.”[D. Meier et al., “A National Survey of Physician-Assisted Suicide and Euthanasia in the United States,” NEJM, 4/23/98, p. 1195]
The national survey, conducted in 1996, polled doctors in specialties most likely to receive requests from patients for assisted suicide or euthanasia, specialties such as cardiology, oncology, geriatrics, family practice, neurology, hematology, and internal medicine. [p. 1199] Of the more than 3,100 physicians who were originally sent questionnaires by mail, 1,902 (61%) completed the survey. [p. 1195] The questionnaires were entirely anonymous. [p. 1193]
The survey found that the number of doctors who would end a patient’s life would likely increase if assisted suicide or euthanasia became legal in their state. While 11% indicated that there are circumstances in which they would write a lethal prescription for a patient under “current legal constraints,” that figure more than tripled to 36% if the practice were to be legally permissible. Likewise, 7% indicated that they would give a lethal injection to a patient under certain circumstances despite legal constraints, while 24% said they would do so if the practice was legal. When asked if they had actually ever given a lethal injection, 4.7% said they had. One doctor reported giving 150 lethal injections. [p. 1195] Out of 38 doctors who reported their most recent experience with lethal injections, only 43% said that they had administered it themselves. The remaining physicians (57%) said that they had asked someone else to give the deadly injection (nurses in 57% of the cases; another physician in 32% of cases) or they had ordered that the dosage of an already established intravenous sedative or analgesic be increased. [p. 1196]
Patients’ requests for assisted suicide outnumbered requests for euthanasia, with 18.3% of the doctors polled reporting that they had received a request from a patient for a lethal prescription, versus 11.1% having received a request for a lethal injection. [p. 1195]
While 95% of the lethal prescription requests were made by the patients themselves, 54% of the requests for death by lethal injection were made by a third party, usually a family member or partner. Doctors polled indicated that the lethal injection requests were “characterized as indirect rather than explicit” in 79% of the cases. Additionally, doctors reported that 5% of the patients who received lethal prescriptions and 7% of patients who received lethal injections were “confused 50% or more of the time.” The doctors also said that they tried to “dissuade [the] patient from hastening death” in only 11% of the lethal injection cases and 34% of lethal prescription cases. [p. 1197; Table 4]
Diane E. Meier, M.D., who headed the survey’s research team, said the study showed that the number of physician-hastened deaths was small and should not be the basis for legalizing assisted suicide or euthanasia. “If it’s only a rare event, which is what our study shows, I don’t think it makes sense to legalize a practice which carries significant risks to the most vulnerable members of our society, those who are sick and dying,” she told reporters. (See also “Researcher Changes Stand on Assisted Suicide” on p. 5.)
But another of the survey’s co-authors, assisted-suicide advocate Timothy Quill, M.D., sees the survey as justification for changing laws to accommodate doctors who would feel more comfortable ending patients’ lives if the practice were legal. “Are [doctors] turning their backs on their patients now because of legal constraints, because the legally safest thing to do is walk away?” he asked. [Boston Globe, 4/23/98]
Big drop in support for assisted suicide and euthanasia among cancer specialists
A new survey of over 3,200 cancer specialists indicates that support for assisted suicide and euthanasia has dramatically declined. The poll, the largest study ever of oncologists on end-of-life issues, surveyed cancer specialists in the U.S., Britain, and Canada. The survey, released by the American Society of Clinical Oncology (ASCO) at its annual meeting, found that support for euthanasia and assisted suicide fell more that 50% over the last three years. According to the new survey, only 22% of oncologists favored assisted suicide for “terminally ill patients in unremitting pain,” versus 45% in a similar survey conducted in 1994-1995. The drop in support of euthanasia (lethal injection) was also dramatic, with the new survey showing only 6.5% support, compared to more than 22% in 1994-1995.
According to the survey, 4% of oncologists have performed euthanasia or assisted suicide within the last year,. Oncologists who cannot get all the treatment and care services they want for their patients—including help from specialists in pain control, fatigue, depression, and general caregiving needs—are more likely to have resorted to performing euthanasia and assisted suicide within the last year. “Education of physicians and access to palliative care services remain the greatest obstacles to providing high-quality end-of-life care,”said ASCO president Dr. Robert J. Mayer. “In fact, the less access physicians have to such services, the more likely they are to grant requests for physician-assisted suicide and euthanasia,” he added. “We must continue to improve palliative care in order to render euthanasia and assisted suicide unnecessary.”
Another significant finding was that 50% of oncologists reported that they do not feel competent to manage or treat depression in dying patients. According ASCO, 40% of patients die with clinical depression. [ASCO, Press Briefing, 5/16/98]
Pain not primary factor in assisted suicide or euthanasia requests
The results of another important study – also released at the annual meeting of the American Society of Clinical Oncology (ASCO) – found that pain is not a major reason behind a terminally-ill patient’s consideration of assisted suicide or euthanasia. Rather, depression and dependence on others are the leading factors for a patient’s interest in ending life.
The study, conducted at six sites across the country, surveyed almost 1,000 terminally-ill patients. All the patients were identified as having less than 6-12 months to live and were interviewed in person. Cancer patients who were depressed and those who “felt less appreciated” were significantly more likely to have thoughts about assisted suicide and euthanasia, as were patients with “more significant caregiving needs for medical assistance, personal care, homemaking, and transportation.” Older patients and black patients were found less likely to consider bringing on death. [D. Fairclough et al., “Interest in Euthanasia and Physician-Assisted Suicide among Terminally ill Oncology Patients: Results from Commonwealth-Cummings Project,” ASCO Abstract, 1998]
According to ethicist and oncologist Dr. Ezekiel Emanuel, who presented the study’s findings at the ASCO meeting in Los Angeles on 5/19/98, severely depressed patients were two times more likely to have contemplated suicide. But, as Emanuel pointed out, doctors who deal with the terminally ill “have poor skills at managing depression.” (See. p. 8.) “When the American public thinks that euthanasia or physician-assisted suicide is acceptable, they are imagining a patient in uncontrollable agony,” Emanuel explained. “Few people think it is justifiable to end the life of a patient because he or she is depressed or needs a lot of help with eating or changing bandages or cleaning the house.”
Emanuel also said that patients’ fears of becoming burdensome to others should be viewed in light of the federal government’s crack down on rising home health care costs. Cutbacks in Medicare payments for both home and hospice programs may send dependent terminally-ill patients into despair. “We have a contradictory social policy,”he said. “The government is worried about home care fraud, but we need to be sure that people get the services they need without enormous economic burdens.” [R. Knox, “Pain is found to trail in considering suicide,” Boston Globe, 5/20/98:A13]
Cost-conscious doctors more likely to participate in assisted suicides
A recent landmark study, published in the Archives of Internal Medicine, found that doctors who are cost-conscious and “practice resource-conserving medicine” are significantly more likely to write a lethal prescription for terminally-ill patients. In fact, these doctors were 6.4 times more likely than less cost-conserving physicians to provide patients with lethal prescriptions upon request.
The objective of the study was to “explore the relationship between general internists’ tendency to conserve medical resources and their willingness to participate in physician-assisted suicide (PAS).” To achieve that objective, 206 general internists in six urban areas of the U.S. were surveyed. [D. Sulmasy et al., “Physician Resource Use and Willingness to Participate in Assisted Suicide,” Arch. Intern. Med., 5/11/98, p. 974]
The study also found that minority doctors were less likely than white physicians to prescribe lethal drugs, but other factors, such as sex, number of years in practice, location, and reported percentage of fee-for-service patients were not associated with the willingness to prescribe lethal drugs. [pp. 974 and 976]
The research team, headed by Daniel P. Sulmasy, M.D., from Georgetown University’s Center for Clinical Bioethics, concluded:
“The association we report does not constitute proof that abuse of PAS will result from the legalization of this practice in a cost-constrained environment. Nonetheless, it suggests a sobering degree of caution in legalizing PAS in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care. This information should be carefully considered and studied further as policy-makers, lawyers, and judges debate whether PAS should be legalized.” [p. 978]
Of interest: Another recent study, co-authored by Sulmasy, found that, in paired interviews, terminally-ill patients and their chosen surrogate health care decision-makers were in agreement on end-of-life choices in only 66% of the cases. Surrogates were more accurate at predicting patients’ wishes for more “invasive procedures,” like ventilator care and CPR. Generally, the surrogates chose for the patients the treatment option they would have chosen for themselves. [D. Sulmasy et al., “The Accuracy of Substituted Judgments in Patients with Terminal Diagnoses,” Annals of Internal Medicine, 4/15/98, pp. 621-629]
Researcher changes stand on assisted suicide
Diane E. Meier, M.D., lead author of the “National Survey of Physician-Assisted Suicide and Euthanasia in the United States” (NEJM, 4/23/98; see Research in Review in this Update), has changed her position on assisted suicide. “Some years ago, I believed that doctor-assisted suicide should be legalized and that terminally ill people in great pain deserved more control over the circumstances of their death,” she wrote in the New York Times the day following the publication of her survey. “But after caring for many patients myself,” she explained, “I now think that the risks of assisted suicide outweigh the benefits.”
In the past, Meier—an associate professor of geriatrics and director of the Palliative Care Initiative at the Mount Sinai School of Medicine in New York City—played a major role in attempts to mainstream assisted suicide within professional circles. She co-authored a number of medical journal articles with assisted-suicide advocate Dr. Timothy Quill, including a landmark article proposing clinical assisted-suicide guidelines for the “care” of the “hopelessly ill.” [“Care of the Hopelessly Ill: Proposed Criteria for Physician-Assisted Suicide,” NEJM, 1992, 327:1380-4]
But now, Meier rejects the argument that guidelines or “strict regulations” will reduce chances of abuse and protect vulnerable patients. She now holds that “rules would be difficult, if not impossible, to enforce.” Using guidelines contained in Oregon’s new assisted-suicide law as examples, Meier explained:
Dying patients, especially the elderly, rarely remain consistently alert as mandated by the Oregon law. Instead, “intermittent confusion, anxiety and depression are the rule rather than the exception, inevitably clouding judgment.”
The guideline that a patient must have six months or less to live in order to qualify for assisted suicide assumes “that such a prognosis is possible” instead of recognizing the “uncertainty inherent in such predictions.” According to Meier, “Abundant evidence shows that accurately predicting when patients are going to die doesn’t become possible until just days before death.”
The mandate—contained in the Oregon law that doctors certify that patients requesting death are not being coerced—is, in Meier’s words, “an impossible task, given the financial and other burdens that ill patients pose to their families.” “Indeed,” she wrote, “legalizing assisted suicide is coercive in and of itself. Society would no longer promote the value of each life, and instead sanction an expedient death rather than continued care and support.”
One of Meier’s major concerns is that “legalizing assisted suicide would become a cheap and easy way to avoid the costly and time-intensive care needed by the terminally ill.” Patients, she wrote, “could feel subtle and not-so-subtle pressure to opt for suicide.” “Our society should not be reduced to offering patients a choice between inadequate care and suicide.” [Diane E. Meier, “A Change of Heart,” New York Times, 4/24/98]
NEWS NOTES
Maurice Genereux, the first Canadian physician to be convicted of assisted suicide, has been sentenced to prison for one day short of two years. Genereux, 51, a Toronto AIDS and HIV specialist, was found guilty last December of prescribing lethal doses of barbiturates to two HIV patients. One patient died as his friends watched; the other lived because a friend found him and went for help. The survivor ended up testifying against Genereux, calling him a “PEZ dispenser for drugs” instead of candy, and saying, “He [Genereux] gave no one hope, none.” (See Update, 11-12/97:9)
Many in Canada said Genereux’s sentence was too lenient. “It’s an extremely light sentence for a very, very serious charge,” said Dr. Philip Hebert, a medical ethics expert who had testified that Genereux was a sick person who was out of control.
Crown attorney Michael Leshner said that he would appeal the sentence. “A very significant penitentiary sentence is appropriate,” he explained. “This case has nothing to do with mercy killing and everything to do with… a doctor not being a doctor.” [Canadian Press, 5/13/98; Toronto Sun, 5/14/98]
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Manslaughter charges against Canadian doctor Nancy Morrison may be reinstated. Morrison, an intensive care doctor, had been charged in the death of a cancer patient in 1996. Reportedly she had given the patient a fatal injection of potassium chloride, but Nova Scotia Provincial Judge Hughes Randall dismissed the case, saying that the prosecution had failed to prove its case. According to the judge, while there was first-hand testimony that Morrison had injected the patient with large doses of painkiller and potassium chloride through an intravenous line, he said that there was evidence that the patient’s IV line was not working, so the fatal drugs might not have ever reached the patient.
But Nova Scotia prosecutor Craig Botterill said that he will ask the Nova Scotia Supreme Court to quash Judge Randall’s ruling. “The Crown will be advancing the position that this case should have been sent to a jury for determination and the preliminary inquiry judge usurped to himself the role of the jury in weighing and ignoring evidence,” the prosecutor said. [The Globe and Mail, 6/6/98]
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British doctor David Moor, 51, has been charged with killing 85-year-old cancer patient George Liddell. Authorities had stopped Liddell’s cremation last year after Moor had told reporters that he had helped as many as 150 patients die over the course of his 30-year career. Moor indicated that the last patient that he “helped” to die was a bowel cancer patient he said was “slowly dying” for three months.
Drug tests were ordered on Liddell’s body and police began an investigation. On 6/10/98, a spokesperson for the Northumbria police announced that Moor was being charged with murder and ordered to appear before the Newcastle Magistrates Court on 7/30/98. [London Times, 6/11/98]
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Australian physician Philip Nitschke is back in the news, this time with a new invention: a suicide pill. It was Nitschke who, in 1996, was responsible for the deaths of four people under the now overturned Northern Territory euthanasia law. The patients died using Nitschke’s “Self Deliverance” software and computer to inject themselves with a lethal drug intravenously.
But now Nitschke is developing a suicide pill composed of readily available ingredients which can be found in most households. The pill, composed of all legal ingredients, would first make people unconscious, then kill them. The first targeted market is Britain, and then, later this year, internationally over the Internet, so that people can kill themselves without the hassle of consulting a doctor. “This so-called ‘technical solution’ has the ability to totally change the face of the debate,” Nitschke said. “The fact that this work is going on should surprise nobody,” he added.
The British Medical Association (BMA) has expressed serious concern over Nitschke’s plan. “We are worried about it because you could have people using it for the wrong reasons,” a spokesman said. “Adequate safeguards would be almost impossible to put in place when it is being sold over Internet.”
But it appears that supporters in favor of changing current laws to allow for euthanasia are ready to use concerns like the BMA’s to argue for legalization. “It [the suicide pill] will not be regulated,” said Voluntary Euthanasia Society general secretary John Oliver. “People will be able to buy it on the Internet and it will probably get into the wrong hands, such as those of people who are depressed and suicidal and not incurably ill,” he said. That, according to Oliver, was sad, but a result of the current legal prohibitions to assisted death. [Sunday London Times, 6/7/98]
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Jack Kevorkian’s lead attorney, Geoffrey Fieger 47, wants to be the next governor of Michigan. As a Democratic gubernatorial hopeful, Fieger has been doing well in the polls, given his name recognition, much to the chagrin of some party faithful who don’t want him as their standard-bearer. [Detroit News, 5/31/98]
Fieger recently told TV viewers that “for the first time you are going to get somebody (1) who is highly qualified and (2) who is going to tell it like it is, for no other reason than I believe it’s time for a citizen patriot to step forward and do something right.”
When he announced his candidacy in April, he said, “I am not for death. I am not for assisted suicide.” Later he told those listening that his first act as governor would be to get rid of any assisted-suicide ban that the Legislature passed. [AP, 4/17/98]
Sparks really started to fly, though, after Fieger fired his campaign manager, Sam Riddle, an African American Detroit lawyer with a successful political campaign track record. Fieger fired Riddle after one month, calling him a “lunatic,” “erratic,” and “absolutely insane,” and claiming that Riddle had verbally assaulted a woman in Fieger’s office. “You can go ahead and call me a racist and a bigot,” Fieger said, “and it doesn’t matter. If you assault women in my office, I will stand up and fire you.”
But Riddle did not go down quietly. Instead , he showed up unexpectedly at a Fieger press conference, telling reporters, “The truth is that Geoffrey Fieger is a lying hypocrite.” “Geoffrey Fieger brought me aboard because he knew that he needed Detroit, Detroit’s overwhelmingly black vote. Geoffrey Fieger was looking for a token black to head up his campaign; what he found was that I’m not a token,” Riddle said. “The guy is a bully who does not have the temperament to be governor,” Riddle added. [Oakland Press, 5/21/98; Detroit Free Press, 5/21/98; T. Bray, Detroit News, 5/31/98]
Cecelia Henderson, a friend of Riddle’s, had a loud, verbal exchange with Fieger at the press conference. She said that she had been a campaign volunteer for Fieger until she found out the details of a fight Fieger had with his wife. “Did you beat up your own wife?” Henderson asked. “And now you’re trying to keep it quiet?” Fieger’s response was sarcastic in tone: “Yes, I beat up my own wife… thank you.” [H. McDiarmid, “Fieger’s world: You like soaps, you’ll love this,” Detroit Free Press, 5/21/98]
The Michigan primary is 8/4/98. It remains to be seen if Fieger will get the Democratic nod and face the current governor, John Engler, in November.
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Hawaii’s Blue-Ribbon Panel on Living and Dying, an 18-member panel which reportedly studied end-of-life issues for 18 months, will submit its report to the governor, urging the legalization of both assisted suicide and euthanasia. “If an individual wants to live as long as medical professionals allow them to, as technology allows them to, that’s perfectly all right,” explained panel chairman Hideto Kono. “But for those who really feel that they’ve reached a point where they want to pass on, we don’t want our system to prolong his death,” he said.
But panel member Patricia Lee, a registered nurse and author of the group’s dissenting report, said the panel did not study the implications of legalizing assisted suicide or euthanasia. “It is apparent,” she said, “that in light of these highly critical public issues, that the legalization of physician aid in dying must be opposed as the potential dangers associated with its legalization surpass any perceived advantages that may be anticipated in certain cases.”
State lawmakers also warned that the legalization of both practices would be difficult if not impossible. Senate Health Co-Chairman Andrew Levin (D, Kau-South Kona) said, “I think it would have to be done extremely carefully, if at all, and with some guarantees and safeguards that I can’t imagine how we would craft for it to be sufficient.” During the last legislative session, six euthanasia and assisted-suicide bills were introduced, but not one got a public hearing.
The governor’s blue ribbon panel did manage to agree on one thing: All members voted to oppose involuntary euthanasia. [Honolulu Star-Bulletin, 5/28/98]
