NCCB Secretariat for Pro-Life Activities
Oregon: "Botched" Suicides, Flawed Report
Oregon's second annual report on the state's experiment in physician-assisted suicide has raised more questions than it answers – about the Oregon law itself, and the credibility of its proponents.
The report by the Oregon Health Division (OHD) was issued February 24 and published in the New England Journal of Medicine [see page 3]. It shows 27 reported cases of assisted suicide in 1999, up from 16 in 1998 (which in turn is a corrected figure, for the state reported only 15 cases last year but later found it had omitted a case that was reported late in the year). It also shows that Oregon physicians are entertaining a broader range of conditions as making a patient eligible for assisted suicide, as the practice moves beyond cancer to cover patients with AIDS, Lou Gehrig's disease (ALS) and obstructive pulmonary disease.
Prompting the greatest controversy about the report, however, is what it does not show. While the OHD found no sign of any abuse of the law's guidelines, news reports have documented several problematic cases. One example is the case of Patrick Matheny, who was given active "help" in taking lethal drugs by a relative when he found himself too physically disabled to take them; this prompted the state attorney general's office to suggest that such "assistance" for persons with disabilities who want to die may be mandated by disability rights laws [see February/March 1999 Life at Risk]. In October, the case of Kate Cheney dramatized the forum-shopping that has allowed patients and families to bypass mental competency requirements: Cheney's adult daughter, described as "somewhat coercive" even by the psychiatrist who approved the suicide request, simply went from one physician to another until she found one willing to find her mother competent to undergo assisted suicide despite her signs of dementia [see September/October 1999 Life at Risk].
The new OHD report shows that only 37% of the patients killing themselves in 1999 received a psychiatric evaluation. The report also comments on interviews with family members in some of the cases – but provides no check on physicians' account of events, since the family member to be interviewed in each case was generally selected by the physician himself.
A final case illustrating deficiencies in the OHD report came to light as the report was issued, with publication of the March 2000 issue of the Oregon newsweekly Brainstorm [see www.brainstormnw.com]. The magazine reported a case of "botched suicide" in which a man took the prescribed lethal dose, but lingered and suffered so terribly that his wife called 911 and had him hospitalized. The man later died, apparently of natural causes, in a nursing facility. "Right to die" advocates discussed the case at a local seminar in December, but had apparently concealed it from the public and from Oregon authorities.
The "botched suicide" problem is given further attention by a Dutch study printed in the same issue of the New England Journal of Medicine as OHD's report [see page 4]. The study shows that 18% of physician-assisted suicides in the Netherlands go awry, leading doctors to dispatch their patients more directly by lethal injection (an option currently not allowed under Oregon law).
In 1997, when this study was available only in Dutch publications, opponents of assisted suicide cited it to support repeal of Oregon's assisted suicide law. However, supporters of the law aired television ads declaring that "you could look forever and you won't find that study -- because it doesn't exist" [The Oregonian, 10/15/97]. Oregon voters believed the latter claim and upheld the assisted suicide law -- only to discover now, over two years later, that the study existed all along.
Oregon Airs "How-To" Suicide Video
Derek Humphry, author of the 1991 suicide handbook Final Exit, has produced a "how-to" video based on his book which has been aired on cable television in Oregon. Public access stations in Eugene and Springfield broadcast the video guide February 2. In the program Humphry shows how he mixed barbiturates into coffee to aid his first wife's suicide, and demonstrates the use of plastic bags and other means for killing oneself.
Suicide prevention experts denounced the video for dispensing lethal information to a general public that includes vulnerable and depressed people. Physician-assisted suicide advocate Barbara Coombs Lee joined in this criticism, calling the video "reckless" and "dangerous" because "it can give people the means to act on impulsiveness" [The Oregonian, 1/31/00]. But Oregon's largest newspaper editorialized that Coombs Lee and others who helped pass Oregon's assisted suicide law created the "climate" in which airing such a video is possible and seen by some as acceptable. "This show never would have been televised before the campaigns for assisted suicide," said the editors, who called the video "an appalling, predictable progression in the campaign to push assisted-suicide in Oregon" [The Oregonian, 2/1].
As if to underscore the editorial's message, a Dutch-language Web site on how to kill oneself is causing considerable chagrin in the Netherlands, where physician-assisted suicide has been permitted for years. Members of the Dutch Parliament have asked the Prime Minister to take action against this site and others which may pose a danger to minors. Visitors to the site can listen to Pink Floyd's song "Goodbye Cruel World," and learn about suicide by drugs, carbon monoxide and other means. "Our society is obsessed with the problem of death," notes Bart Cusveller of the pro-life Center for Medical Ethics [Associated Press, 1/31].
States Dispatch Assisted Suicide Bills
Despite evidence of a growing practice of assisted suicide in Oregon [see pages 1 and 3], the state continues to be alone in this experiment more than five years after the Oregon law was first approved.
On January 31, a bill to legalize physician-assisted suicide in California quietly died when the deadline passed for bringing it to a vote in the state Assembly. Dion Aroner's bill was shepherded through two committees last year with help from the Assembly's Democratic leadership, who temporarily replaced two committee members with supporters of the bill in order to bring it to the floor [see May 1999 Life at Risk]; but even such tactics could not garner majority support in the full Assembly.
On February 3, the state Senate in New Hampshire "overwhelmingly rejected" a similar bill [Concord Monitor, 2/4]. The Senate defeated a motion to proceed to a third reading of the bill, 22-to-2, then approved a motion that it is "inexpedient to legislate" in this regard, 19-to-5.
Maine, where assisted suicide supporters have gathered enough signatures to place a legalization measure on the November 2000 ballot, seems to harbor the only serious current effort to follow Oregon's lead. Early polls suggested that legalization would be supported by seven out of ten Mainers [Associated Press, 1/3]. However, in what has been called "an eye-opening about-face," a new poll conducted for the Bangor Daily News at the end of February shows 53% of regular voters opposing the measure and only 38% supporting it, with 9% undecided. Veteran Maine pollster Christian Potholm of Bowdoin College says these new figures are more consistent with his own polling in recent years, which shows 40% statewide support for legalization and 40% opposition with 20% undecided [Bangor Daily News, 3/6].
The Maine legislature has repeatedly rejected legalization proposals, and the state's hospice and medical associations oppose the new ballot initiative [Bangor Daily News, 2/17].
Oregon's Second Year: Flawed Data, Disturbing Trends
The Oregon Health Division (OHD) released data on the state's second year of legalized physician-assisted suicide on February 24. The report is available on the OHD's Web site [www.ohd.hr.state.or.us/cdpe/chs/pas/ar-index.htm] or as a journal article: A. Sullivan et al., "Legalized Physician-Assisted Suicide in Oregon -- The Second Year," 342 New England Journal of Medicine 598-604 (Feb. 24, 2000).
Even the OHD admits that the information in this report is unreliable and incomplete:
- All reports are from physicians and families personally involved (and the family member interviewed by the OHD was generally chosen by the physician involved). The OHD says that each doctor's report "could have been a cock-and-bull story." OHD Center for Disease Prevention & Epidemiology, "A Year of Dignified Death," CD Summary, March 16, 1999 [www.ohd.hr.state.or.us/cdpe/].
- Doctors have an incentive to hide their abuses, because the OHD must report for further investigation any known case of noncompliance with state guidelines. "Because of this obliga-tion, we cannot detect or accurately comment on issues that may be under reported.." Id.
- News media have revealed abuses ignored by the state's report: the Matheny case, where a family member actively "helped" a patient ingest lethal drugs (The Oregonian, March 17, 1999); the Cheney case, where an adult daughter described as "somewhat coercive" shopped around to find a physician willing to disregard her mother's dementia and aid her suicide (The Oregonian, October 31, 1999); and a recent "botched" assisted suicide where the drugs caused grave complications but did not end the patient's life [Brainstorm, March 2000]. While suicide advocacy groups knew about this last case, the OHD says it did not.
- The annual number of assisted suicides increased from 16 to 27. (Last year's report claimed 15 cases, but missed one death occurring late in the year.) Illnesses prompting a suicide decision have expanded beyond cancer to include debilitating conditions with an ultimately fatal prognosis -- AIDS (1 case) , Lou Gehrig's disease (4), obstructive pulmonary disease (4).
- Only 10 patients (37%) were tested for mental competency. Less than a third (31%) received a lethal prescription from the first physician they approached, but they found another physician. (The active involvement of suicide advocacy groups, found in 11 of the first year's cases, was not assessed the second year.)
- All deaths were induced by an overdose of federally controlled substances (barbiturates). The drugs used for these suicides (43 since 1998) were all prescribed using a federal license from the U.S. Drug Enforcement Administration. Despite this commitment to the most powerful drugs, three patients took over 11 hours to die, and one took 26 hours to die.
- As in the first year, physical pain took a back seat to other reasons for suicide. Physicians say "loss of autonomy" and "decreasing ability to participate in activities that make life enjoyable" were each cited by 81% of patients; worsening pain was cited by only 26%.
- Families say almost half the patients (47%) cited becoming "a burden on friends and family" as a reason for suicide. Three patients (16%) were in Oregon's Medicaid program, a rationed system which funds assisted suicide while denying coverage for 171 treatments seen as less cost effective.
Background: New Reports on Dutch Euthanasia
Two new studies published in U.S. medical journals illustrate the practical side of Dutch euthanasia practice – and some of its problems.
Writing in the New England Journal of Medicine, Dutch experts report that "there may be clinical problems with the performance of euthanasia and physician-assisted suicide." Studying hundreds of cases from 1990-1991 and 1995-1996, they find "complications" (e.g., vomiting) in 7% of assisted suicides, and "problems with completion" (failed suicide or lingering death) in 16%. Out of 114 assisted suicides, 21 (18%) became cases of active euthanasia as the physician resorted to a lethal injection to solve these problems. Clinical problems with active euthanasia were less common but still occurred, with 3% of cases involving "complications" and 6% involving "problems with completion." Such problems did not improve in the later study period, and did not seem to depend on the extent of a physician's experience in assisting suicide [J. Groenewoud et al. in 342 New England Journal of Medicine 551-6 (Feb. 24, 2000)].
In an accompanying commentary, U.S. physician Sherwin Nuland notes: "This is information that will come as a shock to the many members of the public – including legislators and even some physicians – who have never considered that the procedures involved in physician-assisted suicide and euthanasia might sometimes add to the suffering they are meant to alleviate and might also preclude the tranquil death being sought." He says the study may actually under-report problems: 10 percent of physicians refused to take part in the study, and "it seems likely that the physicians whose patients experienced the worst complications would be most reluctant to answer questions about untoward events."
Dr. Nuland adds: "Opponents of physician-assisted suicide will look at these complications as evidence to support their viewpoint, and they are justified in doing so." But he and others who support the practice believe instead that "thorough training in techniques must be made available." The medical profession, he says, must provide training in effectively causing death "with the attention to detail that all aspects of medical practice demand" [S. Nuland, Id., 583-4].
In the Archives of Internal Medicine, another study shows that 58% of Dutch nursing homes have "written guidelines" for euthanasia and assisted suicide, with 90% deeming the practices acceptable in some circumstances. Of the 165 guidelines allowing these practices, 65% mention all "official requirements" for licit practice; only 45% exclude mentally incompetent patients from eligibility. 90% of these guidelines define "euthanasia," but 13% of the definitions "deviated" significantly from official definitions – with six guidelines leaving out the requirement that it is only practiced "on request." The authors conclude that such guidelines "can be improved in many aspects" [I. Haverkate et al., in 160 Archives of Internal Medicine 317-22 (Feb. 14, 2000)].