Will Oregon Law's Third Year Be Its Last?

As Oregon issued a report on its third year of legalized physician-assisted suicide, expectations grew that the Bush Administration may soon act to prevent use of federally controlled drugs for this state's unique experiment in lethal medicine.

Since 1998, due to a legal opinion by U.S. attorney general Janet Reno, Oregon physicians have used their federal prescribing licenses from the Drug Enforcement Administration to order controlled substances – usually secobarbital – for use in terminally ill patients' suicides. However, new attorney general John Ashcroft was an outspoken critic of the Reno opinion when he served in the U.S. Senate. He authored a 1997 letter to Reno signed by seven other Senators urging a contrary opinion, and criticized her final ruling as "bending the law" to facilitate assisted suicide. George W. Bush also criticized the ruling and endorsed a bill to reverse it, the Pain Relief Promotion Act, during the presidential campaign.

The Oregon Health Division's third annual report on operation of the "Death with Dignity Act," released February 22 and summarized in the New England Journal of Medicine the same day, was said by the law's supporters to offer "compelling evidence" that the Act "has given Oregon citizens comfort and control at the end of their lives." Said Estelle Rogers, executive director of the Death with Dignity National Center: "Oregon is a model for the nation, a place where doctors and patients alike approach end-of-life issues with due seriousness and compassion. We believe it's time for President Bush and the Attorney General to do the same" [U.S. Newswire, 2/21/01].

But the same report hailed by Rogers as "a third year of good news" was said by a prominent critic of Oregon's law to confirm that "the assisted-suicide experiment has failed." Dr. Gregory Hamilton of Physicians for Compassionate Care says that Oregon officials monitoring the practice of assisted suicide "have neglected to report meaningful results." Case reports are chiefly self-reporting by the physicians involved, and no effort is made to find "complications" or problems not reported by those assisting the suicide [PCC press release, 2/21/01].

The Oregon Health Division reported 27 deaths from physician-assisted suicide in 2000, the same number as in 1999. The only case it found of incomplete compliance with the Act was one in which a physician submitted a consent form signed by one witness instead of two. Dr. Hamilton notes, however, that the chief case of assisted suicide to receive extensive news reporting in 2000 showed more irregularities than this.

The case of Joan Lucas received feature-length coverage for two days in her local newspaper in June. Suffering from Lou Gehrig's disease, she originally tried and failed to commit suicide by herself on January 16 – but she and her family soon found more expert "assistance" and she died on February 3. The doctor who wrote the lethal prescription says he requested a psychological evaluation "because I wanted to cover my ass" – and that evaluation consisted of a mailed "personality inventory" questionnaire which the family filled in together, "cracking up" with laughter as they read some of the questions. While the survey showed signs of depression, the psychologist felt that depression was a "normal response" to Joan's terminal illness and so approved the suicide request [Medford Mail Tribune, 6/25/00 and 6/26/00].

The state's official report shows no sign of such problems. It does indicate that only 19% of the patients in 2000 received any psychological evaluation (compared to 37% in 1999). And while 26% of the patients cited a concern about being a "burden" on others as a reason for their suicide in 1999, that figure jumped to 63% in 2000 [see page 3 for details].

News Briefs

Kevorkian's Cases Reviewed

A medical examiner from Oakland County, Michigan and three researchers from the University of South Florida have studied key characteristics of 69 patients whose suicides were assisted by Jack Kevorkian between 1990 and 1998. Their findings are published in the December 7 New England Journal of Medicine.

According to medical examiner L.J. Dragovic and colleagues, autopsies show that only 25 percent of Kevorkian's clients were terminally ill when he helped them kill themselves. "Seventy-two percent of the patients had had a recent decline in health status that may have precipitated the desire to die." However, "no anatomical disease was confirmed at autopsy" in 5 of the 69 people. In light of the generally lower rate of suicide among women, it was notable that 71% of these patients were women. Persons who were divorced or never married were over-represented among Kevorkian's clients, "suggesting the need for a better understanding of the familial and psychosocial context of decision making at the end of life" [L. Roscoe, J. Malphurs, L. Dragovic, and D. Cohen, "Dr. Jack Kevorkian and Cases of Euthanasia in Oakland County, Michigan, 1990-1998," Correspondence, 343 New England Journal of Medicine 1735-6 (Dec. 7, 2000)].


Euthanasia Cases in the News

• In Los Angeles, former respiratory therapist Efren Saldivar was charged with six counts of murder in January for allegedly giving lethal injections to patients at Glendale Adventist Medical Center in 1996 and 1997. Saldivar has reportedly called himself an "angel of death" and confessed in 1998 to hastening "anywhere from 100 to 200" deaths, but later retracted the confession. He is also the plaintiff in several civil suits for wrongful death, though some of these have been dismissed for lack of evidence. A hearing in his criminal trial is scheduled for the end of March [Los Angeles Times, 3/10/01, 1/13/01, 1/11/01].
  
  
• In Springfield, Massachusetts, jury deliberations began February 23 in what has been called one of the most sensational murder cases in western Massachusetts history. Kristen H. Gilbert, a 33-year-old nurse, is accused of killing four patients at the Veterans Affairs Medical Center in Northampton and trying to kill three others in 1995 and 1996, using unauthorized injections of adrenaline [Springfield Union-News, 2/25].
  
  
• In Oakland County, Michigan, state officials have revoked the license of 37-year-old hospice nurse Anne Nicolai and are weighing criminal charges, after she acknowledged giving three patients overdoses of morphine to hasten their deaths. The deaths occurred in 1996 and 1997, but investigators only learned there was anything suspicious about them last summer when they received an E-mail Nicolai had written to her boyfriend. The message reportedly revealed details of the three deaths as part of Nicolai's effort to make peace with herself and the world after "finding God" [Detroit News, 2/23/01, 2/22/01].

Oregon's Third Year of Physician-Assisted Suicide: Details and Concerns

On February 22 the Oregon Health Division (OHD) released its third annual report on legally permitted physician-assisted suicides in the state.

These annual reports provide no independent assessment of complications or possible abuse of the state's guidelines, and are not designed to do so. They are based primarily on accounts by the prescribing physicians. The OHD says it must report for further investigation any known case of noncompliance with the state guidelines, so "we cannot detect or accurately comment on issues that may be under reported." In short, the doctors filing reports have an incentive to hide their mistakes or deliberate violations of the law. Indeed, as far as the OHD knows, 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/].
With these caveats in mind, the report finds:

• Twenty-seven Oregonians died in 2000 after ingesting lethal overdoses legally prescribed by their physicians. This number was 27 in 1999 and 16 in 1998. The total number of lethal prescriptions written was 39 (compared to 33 in 1999 and 24 in 1998); some patients died of their underlying illness or were still alive when the year ended. Prescribing drugs for the 27 deaths in 2000 were 22 different physicians.
  
  
• Each case seems to have used controlled substances, requiring a federal prescribing license from the Drug Enforcement Administration. In at least 96% of cases, the barbiturate secobarbital was used. While one patient regurgitated some of the lethal dose, all patients died 5 to 75 minutes after ingesting the drug.
  
  
• A startling 63% of these patients (compared to 26% in 1999 and only 12% in 1998) cited fear of being a "burden on family, friends or caregivers" as a reason for their suicide.
  
  
• The most commonly cited reason for suicide was a concern about "loss of autonomy" (cited by 93% in 2000, compared to 78% in 1999). 96% cited several concerns as contributing to their decision.
  
  
• 30% cited concern about "inadequate pain control" as a reason for their death (compared to 26% the year before), despite claims by the Oregon law's defenders that legalizing assisted suicide has improved pain control and should have reduced or eliminated such concerns.
  
  
• Also rising is the percentage of victims who were married (67%, up from 44%) and who were female (56%, up from 41%). One can surmise that some older married women in Oregon are receiving the message that they are a "burden" on husbands and other relatives, and then opting for assisted suicide.
  
  
• The patients' median age was 69 (compared to 71 in 1999). 78% had cancer (compared to 63% in 1999) and 22% had other illnesses.
  
  
• The patients were highly educated: "Patients with a college education were eight times more likely to participate than people without a high-school education."
  
  
• Despite a medical consensus that the vast majority of suicidal wishes among the sick and elderly are due to treatable depression, in only 19% of these cases (compared to 37% the previous year) did a physician refer the patient for any psychological evaluation.
  
  
• The median time between a patient's initial request for assisted suicide and his or her death by overdose also decreased markedly, from 83 days to 30 days.

Background: Suicide Requests and the Role of Depression

In the November 15, 2000 Journal of the American Medical Association, a special issue dedicated to end-of-life care, Drs. Linda and Ezekiel Emanuel and Diane Fairclough report on a survey of 988 terminally ill patients receiving care in five cities and one rural county in the U.S. Some of their findings:

• 60.2% of the patients supported euthanasia or physician-assisted suicide (PAS) in a hypothetical situation of unremitting pain, but only 10.6% had seriously considered such things for themselves.
  
  
• While a majority supported euthanasia or PAS in a case of unremitting pain, "less than a third support it when the patient desires it because of fear of being a burden on the family." {Ironically, 63% of the patients receiving assisted suicide in Oregon last year were motivated by fear of being a burden on others, while only 30% cited unrelieved pain as a consideration – see page 1.)
  
  
• Those most likely to consider euthanasia or PAS for themselves were those who had depressive symptoms, substantial caregiving needs, and pain. Those least likely to consider it were those who felt appreciated, were 65 years old or older, were African American, or were religious.
  
  
• At a follow-up interview, half the patients who had considered euthanasia or PAS for themselves had changed their minds, while an almost equal number of patients had begun considering these interventions, especially those who had developed depressive symptoms or dyspnea.
  
  
• Of the 256 patients who died during the study, only one (0.4%) died by euthanasia or assisted suicide, one unsuccessfully attempted suicide, and one repeatedly asked to have her life ended but family and physicians refused.
  
  
• The authors note "a tension between attitudes and practices, between the reason people find euthanasia and PAS acceptable – predominantly pain – and the main factor motivating interest in euthanasia or PAS – patient depression." They propose that physicians who are asked to perform euthanasia or PAS "should attend to the possibility of depression and other psychological stressors." [E. Emanuel, L. Emanuel, and D. Fairclough, "Attitudes and Desires Related to Euthanasia and Physician-Assisted Suicide Among Terminally Ill Patients and Their Caregivers," 284 JAMA 2460-68 (Nov. 15, 2000)].

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