Physician assisted suicide (PAS):

Activity in Oregon: 1998 to 2003

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1998 --The first usage of the law; Reno reversed ban:

On 1998-MAR-26, a woman in her mid 80's died from a lethal dose of barbiturates which had been prescribed by her doctor under this law. She was the first person to publicly do so. She had been fighting breast cancer for 20 years and recently had been told by her doctor that she had fewer than two months to live. She had been experiencing increased difficulty breathing. She made a tape recording in which she said that "I'm looking forward to it. I will be relieved of all the stress I have." Her personal doctor would not help her end her life, so she turned to an advocacy group "Compassion in Dying;" they found a doctor that would assist her. She fell into a deep sleep about 5 minutes after taking the lethal dose of pills; she died peaceably about 25 minutes later.

Bob Castagna, a spokesperson for the Oregon Catholic Conference of bishops said: "This is a tragic and sad day for Oregon and the United States. Assisted suicide has begin in the state of Oregon to our profound regret and sorrow. May God have mercy on all of us."

Gale Atteberry, spokesperson of Oregon Right to Life said: "It makes my heart break that we have stooped so low in society that we allow the terminally ill to kill themselves instead of reaching out with true compassion that would be being with them to the end."

By mid-1988, Attorney General Janet Reno (D) reversed Attorney General Constantine's earlier ruling. She stated "that doctors who use the law to prescribe lethal drugs to terminally-ill patients will not be prosecuted ... there was no evidence that Congress meant for the DEA to have the novel role of resolving the profound moral and ethical questions involved in the [physician-assisted suicide] issue ...the drug laws were intended to block illegal trafficking in drugs and did not cover situations like the Oregon suicide law."

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1998 -- Analysis of the law's effects:

By the end of 1998, one prediction of the anti-choice forces had not materialized. There was no rush of people to Oregon to seek an easy end to their life. Since the law was passed, only about one Oregonian per month has elected to commit physician assisted suicide.

Dr. Arthur Chin of the Center for Disease Control and Prevention was the lead researcher in a study of the physician assisted suicide law in Oregon. The study found that during the calendar year 1998: ₁

Many people expected that large numbers of the terminally ill would take advantage of the law. In fact, very few did - only 23 during 1998.

Of the 23 individuals, 15 committed suicide, usually within a day of receiving the prescription. 6 died from their illnesses without using the medication. 2 remained alive at the end of 1998.

Some had predicted that most of those seeking help in dying would be poor, uneducated, uninsured, or concerned about the financial effects of a long, lingering death or fearful of intractable pain. These predictions did not come true. Gender, education, health insurance status, and fear of pain did not play an influential role in prompting a person to seek help in dying.

The CDC compared these 15 with 43 others with similar fatal diseases but who elected to not seek help. They found a number of determining factors that led people to seek help in dying:

	"Concern about loss of autonomy or control of bodily functions."
	Having never married.
	Being a divorced person.
	Having led an independent life.

13 of the 15 were dying of cancer.

Six of the fifteen had to change doctors at least once to find one willing to write a prescription.

Of the 15 who committed suicide, all were white; 8 were male; their median age was 68 years.

Doctors usually prescribed a fatal dose of Secobarbital, along with an anti-vomiting medicine so that the barbiturate would be properly adsorbed by the body.

Everyone who committed suicide became unconscious within 5 minutes. Most were dead within an hour.

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2000 -- Analysis of the law's effects:

During the year 2000, 27 Oregonians ended their lives with the help of the assisted suicide law. Over the first three years that the law has been in place the number of patients choosing legal PAS has remained at six to nine per 10,000 deaths. "...the proportions of PAS patients married, widowed, divorced or never married resemble those seen among other Oregonians dying from similar diseases." ₂College-educated patients were much more likely to choose PAS than those with less than a high school degree, by a factor of 12 or more.

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2001 -- Second wave of opposition from the Federal Government:

In early 2001, Oregon state senator Ron Wyden wrote Attorney General John Ashcroft asking that the Bush administration not mount an attack on the state law permitting assistance in suicide. There were indications that some political conservative would try again to criminalize physician assisted suicide.

On 2001-NOV-5, Attorney General John Ashcroft (R) wrote a letter to Asa Hutchinson, chief of the Drug Enforcement Administration. He declared that assisting a terminally ill patient to commit suicide is not a "legitimate medical purpose" for federally controlled drugs. He said that any physicians who use drugs to help patients die face suspension or revocation of their licenses to prescribe federally controlled drugs. This reversed an earlier order in 1998-JUN by his predecessor, Janet Reno (D).

As expected, responses showed the difference of opinion between Republicans and Democrats, and between pro-life and pro-choice groups:

	Governor John Kitzhaber (D-OR) said: "Given everything that the country is going through right now, with the country trying to respond to anthrax, why John Ashcroft picked this moment to inject this divisive issue into the public debate is just beyond me." The state filed motions in U.S. District Court in Portland seeking to block the order.
	David O'Steen, executive director of the National Right to Life Committee said: "We felt that Reno had set up a very improper and bizarre situation that had the act of killing patients with federal substances illegal in 49 states" but not in Oregon.
	White House spokesman Ken Lisaius (R) said that President Bush opposes Oregon's law. "The president believes we must value life and protect the sanctity of life at all stages."
	Robert Dernedde, Executive Director of the Oregon Medical Association expressed a concern over Ashcroft's letter. He said: "If a physician is accused of misusing drugs, he's essentially under an intense degree of investigation. Appropriate pain management is going to be compromised..."We don't need to have federal officials pawing through medical records looking for what they might view as nonmedical."
	Senator Ron Wyden, (D-OR) said Ashcroft's order "is undoing Oregon's popular will in the most undemocratic manner possible. ... Americans in every corner of the nation are going to suffer needlessly."
	Senator Gordon Smith, (R-OR) said the government should not condone the taking of life. He said: "This is a matter of principle, not a matter of politics."

The Attorney General of Oregon, Hardy Myers, quickly initiated a lawsuit to have the Ashcroft's directive declared unconstitutional. A doctor, pharmacist, and three people who may want to kill themselves with a doctor's help were plaintiffs. The federal district court in Oregon quickly issued a temporary injunction which prevented the federal government from enforcing Ashcroft's interpretation of the Controlled Substances Act (CSA). This debate is a difficult one for social conservatives. Most are opposed to granting terminally ill people the right to choose assistance in dying from physicians. But conservatives also generally disapprove of the Federal government interfering with states' rights under the Commerce Clause and the 10th Amendment of the U.S. Constitution. ₃

Ashcroft's case was eventually rejected by the court.

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2001 -- analysis of the law's effects:

During 2001, physicians in Oregon gave fatal prescriptions to 44 terminally ill individuals. Twenty-one of the recipients used them to commit suicide. A total of 91 individuals committed suicide with the help of their physicians since the Death With Dignity law came into effect in 1997. ₄

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2002 -- Further developments:

The government of Oregon initiated a lawsuit in federal court to block the federal Justice Department from taking legal action against Oregon doctors who prescribe medication to assist their patients to commit suicide. A federal judge ruled in favor of the state state law in 2002-APR. ₅It was probably a relatively simple decision, because the U.S. Supreme Court has already ruled that states can permit doctors to assist in the suicide of their terminally ill patients.

In 2002-SEP, the Justice Department is appealing the decision to the 9th U.S. Circuit Court of Appeals. Their argument is that federal law prohibits doctors from prescribing controlled substances to assist in a suicide. The State of Oregon is arguing that they have the right to permit doctors to assist their patients to commit suicide. Kevin Neely, spokesperson for the Oregon Department of Justice said that:

"The fact of the matter is that the issue in front of us right now isn't a question of the ethics. It's a question, really, of whether or not the government has the ability at the federal level to interfere with the local governments...Obviously, in terms of ... ethics this is a serious issue. But that discussion has already occurred twice in Oregon ... and consistently Oregonians have felt overwhelmingly, at least recently, that we have the right to do this."

Mike Howden, spokesperson for Stronger Families for Oregon, a conservative agency, criticized the state government. He said:

"There's a continuing effort to disassociate any moral consideration for the patient. Yet those same folks will tell you that it's immoral for us to not relieve their pain."

A ruling from the court was initially not expected until mid-2003. It actually came in 2004-MAY. Both sides stated that they will appeal the decision if they lost. ₅

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2002 -- Analysis of the law's effects:

During 2002, physicians in Oregon gave fatal prescriptions to 58 terminally ill individuals. Thirty-eight of the recipients used them to commit suicide. The total number of physician assisted suicide cases was 129 between the time that the Death With Dignity law came into effect in 1997, and the end of 2002. _6,7

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2003 -- Analysis of the law's effects:

During 2003, physicians in Oregon gave fatal prescriptions to 67 terminally ill individuals. Forty-two of the recipients used them to commit suicide. The number of physician assisted suicide cases totals 171 since the Death With Dignity law came into effect in 1997. Physician assisted suicide accounts for only one-seventh of one percent of all deaths in the state. Of the forty-two deaths:

	23 were women.
	19 were men.
	41 were white.
	All 42 had health insurance.
	39 were enrolled in a hospice program.
	35 had cancer.
	32 had at least some college education.

Common reasons for choosing assisted suicide were: the loss of autonomy and not being able to engage in activities that made life enjoyable. ₇

William Toffler, MD, the national director of Physicians for Compassionate Care, opposed extending choice in dying to the terminally ill. He said: "The longer you keep an act in place, the more people become desensitized to it, and it no longer causes the appropriate righteous indignation. The report is not at all routine to me, and the closer you look, the uglier it gets."

Peter Goodwin, MD, supports choice and appreciates the presence of assisted-suicide opponents. He is the medical director of Compassion in Dying of Oregon, a family physician and associate professor emeritus at Oregon Health and Science University. He said: "I think the opposing physicians play a hugely important role, because -- in a sense -- they help to ensure the requirements of the law are fulfilled. But as this process goes along, their concerns become more and more peripheral." ₇

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References:

"Oregon's Death with Dignity Act: Annual Report 2000," Oregon Health Division, at: http://www.ohd.hr.state.or.us/
Katherine Pfleger, "Ashcroft to Pursue Suicide Doctors," Associated Press, at: http://www.washingtonpost.com/
Carla T. Main, "Dying for an Injunction: The debate over Oregon." National Review Online, at: http://www.nationalreview.com
New England Journal of Medicine, 2002-FEB-6.
Steve Jordahl, "Ashcroft Appeals Assisted-Suicide Ruling," Family News in Focus, at: http://www.family.org/cforum/
"New law paved way for 38 to commit suicide in Oregon," Quick Hits, Toronto Star, 2003-MAR-6.
Andis Robeznieks, "Assisted-suicide numbers up in Oregon," AmedNews, 2004-APR-5, at: http://www.ama-assn.org/