Death Without Dignity
There are many compelling emotional appeals for physician assisted suicide. An article in the ''Economist'' relates the the position of a physician whose patient is terminally ill with the "policeman's dilemma":
- A lorry-driver is trapped in the cab of his burning vehicle after an accident. The police, fire-fighters, and ambulance service are at the scene, but it is clear he will burn to death before he can be freed. He is in agony. He begs a policeman (who happens to be armed) to shoot him rather than let him burn. The officer does so. This choice—between killing someone and leaving them to die in unbearable pain—is known as the "policeman's dilemma."
Few people would fault the officer for this act of mercy. In 1994, Oregonians passed the Death With Dignity Act, which establishes a legal basis for a physician to prescribe a lethal overdose of barbiturates to a mentally competent, terminally ill patient.
While many people have a philosophical objection to physician assisted suicide, I can understand its legitimacy. In cases of extreme pain or impending lack of autonomy, where the patient truly wishes to die earlier rather than suffer through up to six months of pain and helplessness before death, it seems like the most merciful thing to do.
However, I firmly believe that the decision to hasten death should be the patient's. Any pressure, whether it be from family, a doctor, or another organization, is inappropriate, and in order to protect people from coercion, any request for suicide should be closely investigated in order to reduce the possibility of someone ending their life at the behest of another person. Furthermore, mentally ill or depressed individuals should be protected—a psychiatric evaluation should be required before any prescription is written.
Unfortunately, the Death With Dignity Act fails to provide sound protections for vulnerable people. I urge Oregonians to write your representatives, calling for a reconsideration of the law.
Physician accountability
In the United States, if a patient is injured because a doctor neglects his duties or fails to exercise his medical skills or knowledge, the doctor may be liable for damages, including both economic damages to cover for financial losses resulting from the injury and also compensation for emotional distress. While it may be that medical malpractice lawsuits are often frivolous, the ability to sue for losses due to a physician's negligence is an important protection.
Unfortunately, the Death With Dignity Act effectively eliminates the accountability of a physician when it comes to assisted suicide. In her article "Why Progressives Should Oppose the Legalization of Assisted Suicide," Marilyn Golden writes:
- Most troubling, the California bill and Oregon's law also legalize negligence, by means of the "good faith" standard, which says that no practitioner of assisted suicide will be subject to any legal liability if they act in good faith, something nearly impossible to disprove, making all other rules unenforceable. For everything else doctors do, they are liable if they are negligent. But on assisted suicide, even if negligent, health care practitioners cannot be found violating the law, as long as they practice in good faith.
Why should there be any less accountability for actively prescribing death than for trying to save life? That a doctor acting negligently while performing a life-saving procedure is liable, while a doctor who negligently prescribes a lethal drug is free from all accountability because he acted "in good faith" defies reason. Physicians should be held equally liable for negligence when prescribing drugs to assist in death as for any other medical service they provide.
Oversight
The Oregon Department of Human Services (DHS, previously Oregon Health Division) is charged with collecting and compiling information on assisted suicide in Oregon for an annual report. The International Task Force on Euthanasia and Assisted Suicide (hereafter ITF) has compiled some statistics as reported by DHS, contrasting them with other sources of information. Of note is the fact that DHS "has no regulatory authority or resources to ensure compliance with the law." So, it is possible that some assisted suicides have gone completely unreported. Furthermore, DHS is only required to get information about an assisted suicide from the doctor who wrote the prescription. If a previous physician had denied assisted suicide to a patient for reasons of incompetency, mental illness, or because the patient was being coerced, the DHS reports would not include this data, and the physician who eventually prescribed the drug would not be liable anyway.
Another side-effect of only talking to the prescribing physicians is that data such as complications that occur during assisted suicide could be skewed. Under the Death With Dignity Act, patients administer their own overdoses, with or without the prescribing physician present. According to ITF, "during the seventh year, physicians who prescribe the lethal drugs for assisted suicide were present at fewer than 16% of reported deaths. Information they provide might come from secondhand accounts of those present at death, or may be conjecture." In seven years following the passage of the Death With Dignity Act into law, DHS reported only ten complications, in each of which the patient vomited after taking the overdose. However, ITF references some cases that were covered in the news but not in the reports, and it cites a Dutch study that found that "because of problems or complications, doctors in the Netherlands felt compelled to intervene (by giving a lethal injection) in 18% of cases." Ten cases out of a total of 208 reported deaths is less than 5%, so it is unlikely that this is an accurate account.
Without more oversight, vulnerable people are left unprotected. Physicians should be required to document and report all cases where a patient asks for assisted suicide. (This is currently written in the law, but it is not enforced.) If a physician refuses to write the lethal prescription, he should be required to report the reasons for his decision. Naturally, for some doctors this will be a purely moral decision—it's reasonable for a doctor not to believe in aiding death—but in those cases where there is evidence of coercion, mental illness, or incompetence, this evidence needs to be documented for future reference in case the patient sees another physician.
Coercion
Although the law specificially prohibits coercion of individuals to request assisted suicide, the safeguards in place are weak and easily ignored. While DHS claims that there have been no cases of coercion, N. Gregory Hamilton, an Oregon psychiatrist, related the following in a testimony before the House of Lords in Great Britain. Kate Cheney was diagnosed with terminal cancer. When she asked her physician for assisted suicide, she was referred to a psychiatrist who found her "demented and lacking competence to consent to assisted suicide," acting under her daughter's wishes, rather than her own. But the enraged daughter got the Kaiser Permanente HMO to fund another opinion. "This psychologist admitted Mrs. Cheney could not even remember when she was diagnosed with terminal cancer although it had only been within the last three months. She also wrote that the patient's decision may have been influenced by her family's wishes and her daughter may have been coercive. Nevertheless, she approved the assisted suicide."
Ironically, this came to light when the daughter went to the Oregonian to talk about how cumbersome the system was. That this example of of coercion was not caught (or at least was not reported) by DHS, and that no criminal charges were brought against Cheney's daughter or any physician involved, is another indicator of a great need for more oversight.
Perhaps even more sinister than direct coercion by family members is the subtle financial coercion by health maintenance organizations. Financially, it is far more attractive for an HMO to cover assisted suicide than it is to cover hospice of other long-term care, since the prescribed drugs cost only $35-$50. Although it is illegal for an insurance company to coerce a patient into assisted suicide, Golden argues, "direct coercion is not necessary. If patients with limited finances are denied other treatment options, they are, in effect, being steered toward assisted death."
According to ITF, 36% of patients who have died under the Oregon law were on Medicare or Medicaid, and "Oregon's Medicaid program pays for assisted suicide but not for many other medical interventions that patients need and want." Similarly, many HMOs place a low cap on hospice care, but will pay for assisted suicide. Furthermore, Kaiser Permanente HMO, facing a lack of Oregon doctors willing to prescribe lethal drugs, has tried to recruit doctors willing to do so.
This blatant abuse of the law (and, even more so, of terminally ill individuals) by managed care providers is unforgivable. It is not ethical to cut costs at the expense of lives. To these organizations, assisted suicide is a means to do just that.
Assisted suicide of the mentally ill
Although by law, an individual must be mentally competent to receive assisted suicide, in practice a depressed patient could easily get the drugs. Hamilton testifies:
- Well-respected studies demonstrate that virtually all patients with a high desire for assisted suicide display symptoms of depression or irrational hopelessness. Nevertheless, the Oregon law does not require that the patient receive a psychiatric evaluation. Only if the doctor intending to write the prescription for overdose or the consultant believes that the patient has seriously impaired judgment due to their mental disorder is there any requirement for referral to a psychiatrist. In actual practice, few patients requesting assisted suicide are ever referred for such an evaluation.... When such a referral is made, it is made to a psychiatrist or psychologist chosen by the assisted-suicide doctor and the evaluations tend to be pro forma; so they provide no protective function at any rate. Even if an opinion disallows assisted suicide in a depressed or demented patient, seeking alternative opinions until one that favors assisted suicide can be found is permitted. Thus, the law provides no effective protection for the mentally ill.
In order to protect mentally ill individuals, a psychiatric referral should be required for all assisted suicide requests. Furthermore, the evaluation should actually carry weight—while a second opinion should be allowed, "shopping" for a doctor willing to prescribe assisted suicide needs to be limited. Unfortunately, it may prove difficult to find enough mental health care providers to perform these evaluations, since, according to The Oregon Death with Dignity Act: A Guidebook for Health Care Professionals, only about one-third of psychologists and psychiatrists in Oregon would agree to perform the evaluations.
Take action!
Death is a serious matter. I don't believe it should be taken lightly, whether by advocates or critics of assisted suicide. I have pointed out some serious flaws in Oregon's Death With Dignity Act and its execution. I believe the law is still salvageable—this is, after all, why laws are amendable. But for this to happen, Oregon residents need to take action! Please take a look at the /WriteYourRepresentatives page for information on how to contact your representatives. Since this is a wiki, you can also contribute your own content, so please add to or revise sample letters, write about your experiences with the law, and add to the resources page. With more thoughtfully written legislation and better oversight, I believe we can reach a good balance between the protection of suggestible individuals and the right of a patient to choose how to die.