Oregon

Oregon's Death with Dignity Act confuses medical and legal boundaries and directly affects even members of the public not expressly connected to euthanasia.
  • Oregon's Dept. of Human Services (OHS) “has no regulatory authority or resources to ensure compliance with the law.” 
  • Opponents claim that due to major flaws in the law and the state's reporting system, no-one knows the whole story.
  • The OHD has to rely on the word of doctors and there are no penalties for doctors who do not report prescribing lethal doses for the purpose of suicide. 
  • In the event of a request being denied, pro-euthanasia groups help to find a compliant doctor to prescribe the drugs.
  • Medical treatment for poor people is restricted while the state fully covers suicide prescriptions.
In 1994, the citizens of Oregon went to the polls to vote on legalising physician-assisted suicide. The referendum was known as Measure 16, or the Oregon Death with Dignity Act.

Measure 16 passed by a narrow margin (51% to 49%), but then was challenged in a federal court on constitutional grounds and not allowed to take effect.

Opponents of the Act, campaigned for the repeal of Measure 16, but in November 1997, 60% of Oregon voters supported keeping the Act.

The Oregon Death with Dignity Act allows a terminally ill adult to obtain a doctor’s prescription for a fatal drug dose, for the express purpose of ending their life.

Oregon Death with Dignity Act

In order to qualify for physician-assisted suicide, a person must be an Oregon resident, 18 years of age or older, must be capable of making decisions, and must be suffering from a terminal disease that will lead to death within six months.

A patient must make one written and two oral requests for medication to end his or her life, the written one substantially in the form provided in the Act, signed, dated, witnessed by two persons in the presence of the patient who attest that the patient is capable, acting voluntarily, and not being coerced to sign the request - there are stringent qualifications as to who may act as a witness.

The patient’s decision must be an informed one, and the attending physician is obligated to provide the patient with information about the diagnosis, prognosis, potential risks, and probable consequences of taking the medication to be prescribed, and alternatives, including but not limited to, comfort care, hospice care and pain control.

Another physician must confirm the diagnosis, the patient’s decision-making capacity, and that the patient’s decision is voluntary.

There are requirements for counselling if the patient is thought to be suffering from a mental disorder which may impair his or her judgment, for documentation in the patient’s medical record, for a waiting period, for notification of the patient’s next of kin, and for reporting to state authorities.

The patient has the right to rescind the request for medication to end his or her life at any time.

Having met the above requirements, the patient is entitled to a prescription for medication to end life.

The Act does not authorise a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia. That is, the Act authorises physician-assisted suicide by lethal prescription but explicitly rejects active euthanasia.

In response to concerns raised that patients might be motivated by depression to seek a physician’s assistance in ending their lives, the 1999 amendments to the Act added “depression causing impaired judgment” to the generic “psychiatric or psychological disorder” that the attending physician must determine the patient does not have before prescribing medications.

Only if the doctor intending to write the prescription for overdose or the consultant believes that the patient has seriously impaired judgment due to a mental disorder is there any requirement for referral to a psychiatrist.

In actual practice, few patient’s requesting assisted suicide are ever referred for such an evaluation. The percentage sent for mental health consultation prior to assisted suicide in Oregon has steadily dropped over the years since 1997.

Official report
Oregon Death with Dignity: sixth year report - March 9, 2004

Forty-two patients used legal physician-assisted suicide in 2003 compared with 38 who did so in 2002, according to the sixth annual report of Oregon’s experience with the Death with Dignity Act.

"This is an increase, but the number remains small in comparison to the average 31,000 Oregon deaths every year," said Mel Kohn, M.D., state epidemiologist in the Department of Human Services (DHS). "Overall, about one-seventh of one percent of Oregonians die from taking legally prescribed medication."

The report, released by the DHS, contains demographics and characteristics of those who took lethal medications the previous year. Findings include:
  • The number of prescriptions written for lethal medication increased from 58 in 2002 to 67 in 2003. These numbers have increased every year since 1998, when 24 prescriptions were written.
  • The major reasons patients chose physician-assisted suicide were concerns about losing autonomy, a decreasing ability to participate in activities that make life enjoyable and loss of dignity.
  • Patients more likely to participate in 2003 were more likely to be younger and highly educated, and to live west of the Cascades in comparison to other Oregonians dying of the same underlying illnesses.
  • Rates of death by lethal medication were highest among patients suffering from amyotrophic lateral sclerosis (Lou Gehrig’s disease), HIV/AIDS and cancer.
  • Prescribing physicians were less likely to be present at time the patient took lethal medication: 29 percent during 2003 versus an average of 47 percent during 1998 to 2002. Among the remaining patients, 67 percent took medication in the presence of another health care provider or volunteer.
  • Complications were reported in three instances; all involved regurgitation and none involved seizures.
  • Half of patients were unconscious within four minutes of ingestion and died within 20 minutes. Time from ingestion to death ranged from five minutes to 48 hours.
  • The proportion of patients with a psychological evaluation has fallen from 31 percent in 1998 to 5 percent in 2003. The law requires that if the attending or consulting physician believes the patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, he or she shall be referred for counseling.
  • The most frequently reported concerns included losing autonomy (93%), a decreasing ability to participate in activities that make life enjoyable (93%), and loss of dignity (82%). (The frequency of the latter concern was assessed for the first time in 2003.)
Referring to physicians' reports, in 1999 the OHD admitted that officials had to rely on the prescribing physicians: "For that matter, the entire account could have been a cock-and-bull story. We assume, however, that physicians were their usual careful and accurate selves."

Monitoring the Act
The Oregon Health Division (OHD) monitors how the Act is implemented, but is not required to make its information available for public scrutiny. This has been a continuing source of controversy, as the OHD is accused of withholding data for scientific study.

The OHD is required by the Act to issue an annual report, based on death certificates, interviews and reports filed by doctors and pharmacies.

The International Task Force on Euthanasia and Assisted Suicide, an organisation opposed to euthanasia, says that official reports do not tell the whole story. They claim that 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.

Abuses
On their website, the Task Force lists complications and abuses of the Law, taken from news reports, that are not listed in official records. Among the reports there appears to be evidence of patients who, having been denied the requested medication because they did not meet the legal criteria, "doctor-shopped" until they found one who would provide the prescription.

There are also reports that patients who are depressed or mentally incompetent have been given prescriptions at their own or a relatives request. Read more here.

1999 Survey
One survey of Oregon physicians in 1999 reports that 5% of practicing physicians received at least one request by a patient for a lethal prescription under the Death with Dignity law. The total number of requests received was 221, several of which appeared to be duplicate requests by patients.

Of the 165 patients for which physicians included outcomes in the questionnaire, 29 received prescriptions.

Of the 29 patients with prescriptions, 17 (59%) took the prescription, 11 (38%) died from other causes, and one was still alive at the time of the survey.[42]

Of the 136 patients who did not receive prescriptions, 27 (20%) died prior to the time the provisions of the law were met, 21 (15%) did not meet the legal criteria, and 21 (15%) changed their minds.

In 30 (22%) of the cases, the physician was not willing to provide the prescription, and the physician was not willing to provide a prescription in any circumstance in 40 (29%) of the cases.

Economic factors
Oregon is the only state in the USA that rations medical treatment for poor people who are eligible for Medicaid. Under the rationing programme, while certain pain-relief and life-sustaining treatments are not covered, the state fully covers suicide prescriptions.

In August, 2002, leading health maintenance organization, Kaiser Permanente had its regional ethics committee email 740 doctors for volunteers to administer suicide drugs.

In the first six years that assisted suicide has been legal in Oregon, 38% of patients whose death was reported were on Medicaid or Medicare.

Support groups
Compassion for the Dying, reported that eleven of the fourteen doctors involved in the assisted suicides were members. Approximately 86% of the people who chose to die, were supported by activists from assisted suicide groups.

In the event of a person being denied a request for physician assisted death, it has been noted that Compassion for the Dying has referred people to a doctor who was willing to participate.

The doctor referred the patient to a second physician and to a psychiatrist who supported the decision. Much of the information about the case came from an audiotape the physician made of an interview he had with the patient. An edited version of the audiotape was played for the media by Compassion in Dying the day after the patient’s death.

Hospice and palliative care services
Asked to evaluate the impact the Oregon Death with Dignity Act (the Act) has had on palliative care services in that state, Ann Jackson, Executive Director, Oregon Hospice Association (OHA) found that, after the law was passed, hospice nurses reported that physicians in Oregon were doing better at managing pain. More physicians attended continuing education classes in palliative care after passage of the Act than before.

Jackson has found that “awareness of end-of-life care options is probably greater in Oregon, especially among health care professionals.

Jackson also indicates that proponents of assisted suicide often mislead their audiences by arguing that the only alternative to pain is death. However, Jackson indicates “pain has not been a significant reason for individuals to use [the Act]. Fear of pain appears to be a greater factor than actual pain.” Palliative care provides adequate pain relief as an option.

Problems
According to the 1999 survey of 4,053 physicians eligible to prescribe under the Act, 65% participated in the survey (2,649) and indicated that physicians grant about one in six requests for a prescription for lethal medication and one in 10 requests actually results in suicide.

The study contained some problems reported by physicians who assisted suicide under the Act, including unwanted publicity (3 physicians), difficulty obtaining the lethal medication or a second opinion (3), difficulty understanding the requirements of the law (3), difficulties with hospice providers (1), not knowing the patient (1), or the absence of someone to discuss the situation with (1).

Under-reporting by physicians
In regard to the law’s requirement that physicians confidentially report lethal medication to the Oregon Department of Human Services, some physicians were concerned about reporting because they feared that the patient’s privacy (in 16 cases), their own privacy (in 18), or the privacy of the patient’s family (in 15) would be violated or that retroactive sanctions would be imposed by the Drug Enforcement Agency (in 7).

Four physicians expressed ambivalence about having provided assistance with suicide, though two of the four noted that they had become less ambivalent over time; one deciding not to provide such assistance again. More on the death With Dignity Report can be read here.

See also "Oregon's assisted suicide experience - safeguards don't work."