Nearly eight out of ten Vermont residents favor assisted suicide – or so it would seem. The poll – commissioned by supporters of a Vermont assisted-suicide bill – was taken by Zogby International in December 2004. Assisted-suicide supporters said they hoped the poll results will encourage Vermont lawmakers to consider an Oregon-type law in the next session. (1)
However, poll questions dealing with assisted suicide were framed as a patient’s right’s query. For example, in the first question, respondents had the choice between:
“If I am terminally ill, within six months of dying and with no hope of recovery, the decision about when I should be able to bring a peaceful end to my suffering is mine to make in accordance with my wishes and in consultation with my family and loved ones.” (or)
“Given the sacredness of human life, only God should decide when my life ends.”
The words “assisted suicide” or “suicide” were not used in that, or the other questions.
The poll was an example of the types of polls and surveys done with an eye to manipulating, rather than measuring public opinion. Political organizations take two primary types of polls. The first actually gauges public sentiment so that a campaign can build upon likes, dislikes and biases discovered in the polling. Such polls are generally kept “in house.” The other type is done by asking a question that has been crafted to elicit a particular response. Its purpose is to create a bandwagon effect – to imply that a majority of people approve (or disapprove of a candidate or a legislative measure). Its release is used to sway others to “join the crowd.”
Another example of a manipulative poll was the one commissioned in 2002 by EOL Choices. According to the announced results, “Sixty-one percent of Arizona physicians treating terminally ill patients believe they should have the option of helping their patients hasten their deaths if that is what their patients want, a just released survey shows.” (2)
Certainly, this seemed like astounding support for assisted suicide among Arizona doctors. However, closer reading and simple mathematics painted a different picture.
The survey had been sent to 400 physicians. Only twenty-two percent of those who received the survey responded. And, of those twenty-two percent who responded, sixty-one percent favored hastening a patient’s death. Put in plain numbers: eighty-eight physicians responded to the survey and, of those, fifty-four favored hastening a patient’s death. Yet, the headline on the announcement stated “Arizona’s Doctors Okay Aid in Dying, New Survey Shows.”(3) The impression left was far different than it would have been if the wording had been “Fifty-four Doctors okay aid in dying, New Survey Shows.”
Additionally, while the purpose of both the Arizona survey and the Vermont polls intended to build support for assisted suicide, neither contained the term “assisted suicide.” Instead soft, comforting phrases such as “hasten death,” “death with dignity,” or “aid in dying” took its place.
When people are asked directly about their views on assisted suicide, the results show that the majority of Americans do not favor assisted suicide. In fact, support for assisted suicide is now at its lowest in fourteen years. A CBS News poll, conducted among a nationwide random sample of 885 adults in November 2004, asked, “Should Physician-Assisted Suicide Be Allowed?” Only forty-six percent of those polled said, “Yes,” This was down from a high of fifty-eight percent in 1993.(4)
Ever since the passage of Oregon’s law, the underlying theme of assisted-suicide proponents has been, “It’s working in Oregon.” For example, when a measure that was virtually identical to the Oregon law appeared on Maine’s ballot in 2000 as “Question 1: The Death with Dignity Act,” assisted-suicide supporters from Oregon pitched in to help support the initiative. Dr. Katerina Hedberg (Oregon’s chief epidemiologist who co-authors Oregon’s official assisted-suicide reports), Ann Jackson (executive director of the Oregon Hospice Association), Barbara Coombs Lee (executive director of Compassion in Dying) and former Oregon Governor Barbara Roberts all traveled to Maine to assure voters that Oregon’s law was working well and was problem free. Just as in the 1994 campaign in Oregon, and in subsequent attempts to pass similar laws in Michigan and California, right-to-die advocates used deception and denial to advance their cause.(5)
However, “No on 1” (opponents of the Maine initiative) used effective research and carefully designed material to counter erroneous claims of a problem-free Oregon law. One television ad featured Oregon physician Thomas Reardon who was the immediate past president of the American Medical Association. In it, Reardon described Oregon’s problems and complications with assisted suicide. He related the story of a 911 call made by a panic-stricken family member when the lethal prescription caused complications. The ad concluded with Reardon saying, “And I don’t want Maine to make the same mistake we did.” (6)
The ads were so effective that the “Yes on 1” campaign tried to have them taken off the air. When they were unsuccessful, they enlisted the aid of Oregon’s governor, John Kitzhaber, to appear in an ad to “set the record straight.” “Here’s the truth,” Kitzhaber said. “It’s working well.” (7) He insisted that no assisted suicide under the Oregon law had ever resulted in complications warranting a 911 call. But the No on 1 campaign was able to produce documentation that the case had been the subject of a 2-part article in theOregonian.(8) (Assisted-suicide advocates still adamantly deny the 911 call story even though there is an audio tape of Oregon attorney Cynthia Barrett – who favors assisted suicide – describing the event during a presentation at Portland Community College.(9))
“Question 1, the Maine Death with Dignity Act,” failed, in large part, because Maine voters understood that all was not working well in Oregon.
Nonetheless, assisted-suicide advocates still point to Oregon as the “poster state” where there are no problems or complications related to deaths under the Death with Dignity Act. They point to official reports to support their claims.
For example, in preparation for a repeated attempt to pass an assisted-suicide law in Vermont, EOL Choices (Hemlock) prepared a document for the Vermont Legislative Council that stated: “The Vermont Death with Dignity (DWD) Act is based point by point on the existing Death with Dignity Act in Oregon. The Oregon Act has been responsibly implemented since 1997, with successful utilization of the safeguards built into the Act and with no indication of abuse documented by the Oregon Department of Human Services or any other authority.”(10) Referring to the monitoring and annual reports conducted by the Oregon Department of Human Service, the document claimed, “This monitoring shows the law is working well.”(11)
Thus, it is important to examine briefly both what is contained and what is omitted in those official reports during its first six years of implementation.(12)
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.(13)Since the law, called the “Death with Dignity Act,” went into effect in 1997, six official reports have been published. However, due to major flaws in the law and the state’s reporting system, there is no way to know for sure how many or under what circumstances patients have died from physician-assisted suicide.
The latest annual report indicates that reported assisted-suicide deaths have increased by more than 250% since the first year of legal assisted suicide in Oregon.(14) 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.”(15)
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:||7 (instances of “regurgitation”)|
Physicians who prescribed the lethal drugs for assisted suicide were present at fewer than 30% of reported deaths.(16) Doctors who were not present when the patients took the deadly overdose may not know about complications that took place. Since doctors who prescribe the lethal medication are not legally required to be at the patient’s bedside when the drugs are taken,(17) information they provide might come from secondhand accounts of those present at the death(18) or may be conjecture.
Complications contained in news reports are not included in official reports:
- Patrick Matheny received his lethal prescription from Oregon Health Sciences 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.”(19)
- Speaking to a small group 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….”(20)
- 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.(21) But Barrett would not say exactly which symptoms had taken place in this instance. She has refused to discuss the case since her December 1999 revelation.
In The Netherlands, where assisted suicide has been practiced for many years, 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.(22)This led Dr. Sherwin Nuland of Yale University 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.(23)
Assisted suicide deaths of patients with dementia
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.(24)
Assisted suicide deaths of depressed patients
- 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) became involved.
- Dr. Peter Goodwin, medical director of CID,(25) determined that she was an “appropriate candidate” for death and referred her to a doctor who provided the lethal prescription. An audiotape, made two days before her death, was played at a CID press conference. In it, the woman said, “I will be relieved of all the stress I have.”(26)
- 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, Reagan said he didn’t think that a psychiatric consultation was “necessary.”(27)
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.(28) Under the assisted-suicide law, depressed or mentally ill patients can receive assisted suicide if they do not have “impaired judgment.”(29)Concerning the decision to refer for a psychological evaluation, Oregon epidemiologist Dr. Mel Kohn said, “According to the law, it’s up to the docs’ discretion.”(30)
Patients who received lethal dose more that 6 months before death
|Official Reports:||1 (After the 2nd year, official reports stopped including this category.)|
Lethal prescriptions under the Oregon law are supposed to be limited to patients who have a life expectancy of six months or less.(31) However, 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.(32)
The sixth annual report noted that two patients who received prescriptions in 2002 and another who received the prescription in 2001 died from the lethal drugs in 2003.(33)
The DHS is not authorized to investigate how physicians determine their patients’ diagnoses or life expectancies. If physicians are prescribing for patients whose life expectancy exceeds six months or who do not have a terminal condition, there is no way to find out since the same doctors who are violating the guidelines would have to report their own violation. “[N]oncompliance is difficult to assess because of the possible repercussions for noncompliant physicians reporting data to the division.”(34)
The DHS has to rely on the word of doctors who prescribe the drugs.(35) Referring to physicians’ reports, the reporting division admitted: “For that matter the entire account [received from doctors] could have been a cock-and-bull story. We assume, however, that physicians were their usual careful and accurate selves.”(36)
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.)|
“Many patients who sought assistance with suicide had to ask more than one physician for a prescription for lethal medication.”(37) Patients and 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 prescribed lethal drug doses for patients.(38)
Shortest length of relationship between patient and prescribing physician
|Official Reports:||Less than one week|
Although at least two weeks is supposed to elapse between the first and last requests for the lethal dose,(39) the physician who prescribes the drugs for assisted suicide need not be the same physician to whom the first request was made.
For the third through the sixth years, the doctor-patient relationship in some reported assisted suicide cases was under one week.(40) Thus, either some physicians are not complying with the two-week requirement or they stepped in to write an assisted-suicide prescription after other physicians refused.
Assisted suicide requests based on financial concerns
Data about reasons for requests is based on prescribing doctors’ understanding of patient motivation. It is possible that financial concerns were much greater than reported. According to official reports, 38 percent of patients whose deaths were reported were on Medicare (for senior citizens) or Medicaid (for the poor).(41)However, after the second annual report, the reports have not differentiated between Medicare and Medicaid patients dying from assisted suicide. Oregon’s Medicaid program pays for assisted suicide(42) but not for many other medical interventions that patients need and want.
Clearly, information contained in official reports is incomplete at best. Furthermore, other aspects of the Oregon experience should be taken into account when attempting to understand the practice of legalized 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….” (43)
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.”(44)
Kaiser’s Northwest Regional Medical Director Allan Weiland, MD, called Hamilton’s comments “ludicrous and insulting.”(45) However, it appears that Hamilton was correct, as the involvement of Compassion in Dying indicates.
The assisted-suicide advocacy group, Compassion in Dying (CID), has been involved in the vast majority of Oregon assisted-suicide deaths
If a physician opposes assisted suicide or believes the patient does not qualify under the law, CID may arrange the death. According to Dr. Peter Goodwin, CID’s medical director, about 75 percent of those who died using Oregon’s assisted-suicide law through the end of 2002 did so with CID’s assistance.(46) During the 2003 calendar year, CID was involved in 79 percent of such deaths.(47)
In addition to the impersonal nature of managed care organizations and assisted-suicide advocacy groups that facilitate deaths under the Oregon law, the lack of family involvement or even family notification is troubling.
Family members do not need to be informed before a doctor helps a loved one commit suicide
Family notification is only recommended, but not required, under Oregon’s assisted-suicide law.(48) The first time that a family learns that a loved one was considering suicide could be after the death has occurred.
Oregon’s law provides greater protection for doctors than for patients
While assisted-suicide advocates claim that patients are given new rights under Oregon’s law, nothing could be farther from the truth. Prior to the law’s passage, patients could request, but doctors could not provide, assisted suicide. It was illegal and unethical for a physician to knowingly participate in a patient’s suicide. The law actually empowers doctors by promising them legal immunity if they provide a patient with an intentionally fatal prescription. Yet, advocates still say that the law grants patients a new legal right –the right to ask their doctors for suicide assistance, even though such a request was never illegal. Suicide requests from patients may have been cries for better pain control, support or psychiatric help – but they were never a crime.
In addition, doctors who prescribe assisted suicide under Oregon’s law are exempt from the standard of care that they are required to meet when providing other medical services. Under the assisted-suicide law, a health care provider is not subject to criminal or civil liability or any other professional disciplinary action as long as the provider is acting in “good faith.”(49) This subjective “good faith” standard is far less stringent than the objective “reasonable standard of care” which physicians are required to meet for compassionate medical care such as hospice, palliation or curative treatment.
As a result, a doctor who negligently “participates”(50)s in assisted suicide cannot be held accountable so long as he or she claims to have acted in “good faith.” On the other hand, a doctor who negligently provides other medical interventions can be held legally accountable in civil court regardless of his or her “good faith.”
This lowering of the standard of care for assisted suicide could serve as an inducement for doctors to recommend assisted suicide over palliative care at the end of life.
In the coming months, several states will be considering 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 its reality.
7. “Election politics: Kitzhaber joins Maine debate,” Register-Guard, October 28, 2000. Kitzhaber’s action astounded many people since, as the governor of Oregon, he was intervening in an initiative campaign in another state, taking a position that differed from the governor of Maine.
8. David Reinhard, “The pills don’t kill: The case, First of two parts,” Oregonian, March 23, 2000 and David Reinhard, “The pills don’t kill: The cover-up, Second of two parts,” Oregonian, March 26, 2000.
9. Barrett made her remarks during a “Physician-Assisted Suicide: Counseling Patients/Clients” presentation at Portland Community College in December 1999. Audio tape on file with author. Also, see Catherine Hamilton, “The Oregon Report: What’s Hiding behind the Numbers?” Brainstorm, March 2000, (http://www.brainstormnw.com)
10. Death with Dignity Vermont and End-of-Life Choices Vermont, “The Oregon Death with Dignity Act: Six Years of Data, A Document Prepared for Vermont Legislative Council,” July 12, 2004, p. 2. http://www.deathwithdignity.org/articles/Oregon_DWD_6%20yrs_7.11.04.htm (last accessed December 6, 2004)
21. Johanna H. Groenewoud et al, “Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands,” 342 New England Journal of Medicine (February 24, 2000), pp. 553-555.
25. Dr. Peter Goodwin was an Associate Professor (now professor emeritus) in the Department of Family Medicine at the Oregon Health Sciences University in Portland, Oregon and was Chair of Oregon Right to Die during the campaign to pass Oregon’s assisted-suicide law. He had been active in the Hemlock Society. Speaking at a 1993 Hemlock conference in Orlando, Florida, he explained that he favored both the lethal injection and assisted suicide, but he realized that most people were not yet ready to accept the former so incremental steps would need to be taken.
26. Erin Hoover and Gail Hill, “Two die using suicide law; Woman on tape says she looks forward to relief,”Oregonian, March 26, 1998; Kim Murphy, “Death Called 1st under Oregon’s New Suicide Law,” Los Angeles Times, March 26, 1998; and Diane Gianelli, “Praise, criticism follow Oregon’s first reported assisted suicides,” American Medical News, April 13, 1998.
27. N. Gregory Hamilton, M.D. and Catherine Hamilton, M.A., “Competing Paradigms of Responding to Assisted-Suicide Requests in Oregon: Case Report,” presented at the American Psychiatric Association Annual Meeting, New York, New York, May 6, 2004. (http://www.pccef.oorg/articles/art28.htm)
32. Department of Human Services (DHS), Oregon Health Division (OHD), “Oregon’s Death with Dignity Act: The Second Year’s Experience,” February 23, 2000, Table 2. (http://www.ohd.hr.state.or.us/chs/pas /year2/ar-index.cfm)
46. Transcript of tape of Peter Goodwin, “Oregon” January 11, 2003, presented at 13th National Hemlock Biennial Conference, “Charting a New Course, Building on a Solid Foundation, Imagining a Brighter Future for America’s Terminally Ill,” January 9-12, 2003, Bahia Resort Hotel, San Diego California.
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