Policy Analysis Paper!

Physician Assisted Suicide, After Implementation in Oregon

Criminal Justice 421: Policy Analysis in Criminal Justice

Doctor Scott Tighe

Sample

Executive summary:

There are many quotes and sayings that describe or define life. One of the most famous quotes about life is, “Don’t take life too seriously; you’ll never get out alive” by Elbert Hubbard. The ironic thing about this quote is that it uses death to define life. Death is something that is unavoidable and for most people, unexpected. In 1997 Oregon voters did something that set them apart from every other state in America. They passed measure 16, better known as the Death with Dignity Act. Measure 16 had a tough time passing. It passed with a merely 51 percent vote, just enough to lock it in as law (Oregon Blue book). In August 1995 a court found the measure unconstitutional for violating the Fourteenth Amendment (The United States District Court for the District of Oregon). The court was supported by a coalition of religious groups including the Catholic Church, which perceive PAS as disrespectful of God’s gift of life, and the American Medical Association, all which are afraid of altering physicians’ traditional role of protecting and preserving life. The most influential response was a lawsuit filed in federal district court by a group of physicians, residential care facilities, and concerned Oregon residents challenging the Act on constitutional grounds. Citing the Fourteenth Amendment, the plaintiffs claimed that the Act violated due process and equal protection rights by failing to protect vulnerable patients who may resort to assisted suicide because of undiagnosed depression or coercion.

The Fourteenth Amendment states that “no state shall make or enforce any law which shall abridge the privileges or immunities to citizens of the United States; nor shall any state deprive any person of life, liberty or property without due process” (Scheb, John M). In November 1997, a measure asking Oregon voters to repeal the Death with Dignity Act was placed on the general election ballot (Measure 51, authorized by Oregon House Bill 2954). Voters rejected this measure by a margin of 60 to 40 percent, retaining the Death with Dignity Act. After voters reaffirmed the ‘Death with Dignity Act’ in 1997, Oregon became the only state allowing this practice.

In February 1997, measure 16 was passed by a three- judge panel of the Ninth Circuit Appeals Court (Physician-Assisted Suicide: Ten Years after Death with Dignity Act Passes in Oregon). The fourteenth amendment states that, “no state shall deprive any person of life”, but what if that person doesn’t want to live any longer? What if they have a terminal illness that is causing their body to rapidly deteriorate along with pain and suffering, thus leading to a painful ending of life? The right to die should not be left up to the government to decide. In a time of pain and suffering, a capable human being should be able to decide life or death for themselves. That is why many agree with “The Death with Dignity Act.” This act enables mentally capable, terminally ill patients to choose when to end their own lives through the self administration of, physician prescribed, lethal medication.

Analysis of the Problem:

After fifteen years since Oregon passed this act only two other states have passed a similar act. One being Washington, on November 4, 2008 Washington passed its own Death with Dignity Act, which is almost identical to the one Oregon has in effect now (Should euthanasia). Physician assisted suicide (PAS) has remained a worldwide controversial topic because it raises questions about rights, morals, medical ethics and religious beliefs. For many the actual implementation of PAS created a valid approach and view to end of life care in Oregon. For many, physician assisted suicide is a big discussion point. We have all had to go through the pain of losing someone we cared about, whether it happened suddenly or slowly and painfully. For example, ten years ago, my grandma was diagnosed with cancer for the third time. She decided not to fight the cancer again, but instead just wanted to die. I watched her die slowly and painfully. It was a very hard thing for me to see. At the same time though, it made me happy to be able to spend some quality time with her before she passed. If she would have chosen physician assisted suicide, I wouldn’t have gotten that closure that I wanted with her. For which, I am very thankful. The purpose of ‘death with dignity’ is to end pain and suffering for individuals with a terminal illness. The reason for this evaluation is to explore the pro and cons of the ‘Death with Dignity Act’ and examine some arguments in support of the program. Before PAS was implemented it acquired many negative views because it incorporated taking the life of an individual. This analysis will also determine if the program is fair to all individuals and not a way for people to escape the sufferings of life.

Program Implementation and Monitoring:

Before PAS terminally ill patients would live with pain and suffering until their very end, death, this is a horrible way for any individual to finish their gift of life. Death with dignity is more properly described as a “life with dignity until its very end” (Gentzler, Jyl.). Having dignity is having pride in one’s self, or having self respect. Dying with dignity is almost like dying with pride, knowing you lived a good life. For example, some people would rather die with a strong body, instead of letting it deteriorate to the point of death. That is why the name “Death with Dignity” was initiated. Dying with dignity is what most human beings want, someone in their right mind wouldn’t want to die with pain and suffering and lack of ability to care for themselves. Oregon residents passed the Death with Dignity Act in 1994, but it did not go into effect until October 27, 1997. Although PAS is legal in Oregon, not all physicians are willing to participate in the providing of a fatal prescription to a patient. Many doctors believe that the Hippocratic Oath, which they must take, makes it morally wrong for them, as healers, to assist in ending a life. This issue was resolved by making it acceptable for a doctor to decline to participate in the act. There are also several limitations on who is allowed to participate in PAS. The Oregon law states, that in order to participate, a person must be at least 18 years of age, an Oregon resident, capable of making knowledgeable medical decisions and diagnosed with a terminal illness that will lead to death within six months.  If a person meets all of these requirements they then must make two oral requests to their physician with at least 15 days separating the two requests and provide a written request to their physician with two witnesses’ signatures. The physician must then consult a second physician and if either of them thinks that the patient is not mentally capable of making an educated decision, then the patient must get a psychiatric evaluation to confirm their eligibility to participate in PAS (Should euthanasia). As shown, the process they have set in place to be eligible for PAS is very extensive. They obviously used careful consideration drafting and planning this law with most people’s rights and morals in mind.

Doctors could assume that some physicians could guide their terminally ill patients into undergoing PAS. In an article by Mark D Uehling, he states “For a man named Donald O'Keefe it was his time to die. He was 73. O'Keefe had terminal bone cancer. The bad cells had spread to his throat and beyond, leaving him flat on his back, unable to eat. "He's just lying there, in agony," one observer recalls. "All of his organs were being eaten out and he was alive while it was happening." Mr. O'Keefe wanted to die, but his body refused to cooperate. In a nation of more than half a million expertly trained physicians, none were willing to minister to Mr. O'Keefe in ways that any veterinarian would tend to a crippled horse. Instead it was the considered opinion of the medical community that Mr. O'Keefe would have to let nature take its course. That, after all, was the law” (Dr. Kevorkian looks death right in the eye). This is a perfect example of a patient that could have been aided by PAS, but could never get it. For many people their dream might be to die pain free, but no doctors would go against their oaths as healers to kill another human being. Until, Doctor Jack Kevorkian. More commonly known as, Dr. Death. In the 1980’s Kevorkian wrote many articles to medical journals expressing his interest and support for PAS. Doctor Kevorkian worked in Detroit, Michigan and in 1987 he began advertising himself as a “death consultant.” In 1991, Kevorkians’ medical license was revoked due to his strange interest with death. This did not stop him from assisting 130 people in ending their lives between 1990 and 1998 (Chua-Eoan, Howard). Kevorkian created two machines to assist patients in suicide. The first he called the Thanatron. It injects a lethal dose of medication by an I.V. He called the second machine Mercitron. It uses a canister of carbon monoxide and a gas mask to euthanize the patient. The public had begun to show wide support for Kevorkian and his cause. He was tried in court, but never convicted, for his role in several suicides. On November 22, 1998 Kevorkian appeared on the television show 60 Minutes. While on the show, a videotape that he had made in September of that year was aired showing Kevorkian administering a lethal injection to a 52 year-old man who was in the final stages of Lou Gehrig’s disease. By March of 1999 Kevorkian was charged with second degree homicide and sentenced to 10-25 years in prison. He spent just over eight years in prison and was released in 2007 on good behavior. Since his release from prison he has given countless lectures to thousands of people about his views on PAS. He also had a movie made that portrayed him and his life, wrote two books, and ran for congress (Jack Kevorkian). Sadly Jack Kevorkian died June 3, 2011 at the age of 83. He died at William Beaumont Hospital, where he had been admitted with kidney and respiratory problems. Kevorkian’s willful fight to legalize PAS helped spur the growth of hospice care in the United States. He also made doctors become more sympathetic to those is severe pain (Schneider, Keith). Kevorkian’s argument for PAS, as a means of ending pain and suffering to the terminally ill, has become more widely accepted and supported in recent years. Because of Dr. Kevorkian’s actions, he served an important role; he allowed Americans to acknowledge the intolerable sufferings of the terminally ill (Doctor Death, the Celebrity).

Yet another argument would be, PAS could diminish the trust patients have in their physicians. Trust implies that physicians will do no harm to their patients. That doctors are the healers of our world, not the killers. But, for instance, under the Death with Dignity Act if a patient wants to die, he can chose to do so humanly rather than by self inflicted suicide. No one wants to come home to find their terminally ill family member has committed suicide with a dangerous weapon. For this reason, physicians have implemented and regulated the Death with Dignity Act. Deep down many people would rather have this practice regulated than to allow the further development of self- help methods. Our physicians in the medical community will still be the healers of our world, but by regulating death with medicine and making it a painless act, could help many people. In ways, the medical profession as whole will gain respect if it “medicalized” the dying process rather than leaving the final act to be performed with handguns, plastic bags or illegally acquired drugs. In America, for men, one of the most common forms of death is suicide. Suicide is significantly more likely among men than women. In 2005 in the United States 32,637 suicides were reported, ranking suicide as the 11th most common cause of death for all Americans. Out of the 32,636 suicides in 2005 men accounted for 79% of them (Tewksbury, Richard) Dr. Marcia Angell expresses her views very well in a quote to a newspaper. She states “It seems to me almost self-evident that a dying patient who is suffering unbearably should have the option to end his life. And most such patients will require the assistance of a doctor to do so humanely and with dignity. We're not talking about forcing such patients to end their lives, and we're not talking about requiring doctors to help them. We're merely saying that there should be this choice, that they should be able to exercise the option” (Doctor Assisted Suicide). In the passage by Dr. Marcia Angell she states something very important, “a person should have the right to die humanly”. Humanly means, “in a human manner” or “within the limits of human knowledge and capability” (Webster's Dictionary and Thesaurus). In this aspect, humanly means, using a human being or human knowledge to make dying a more peaceful and non miserable process.

Terminally ill patients, like everyone else, are going to go through the process of death. It is inevitable. There are a few ways to care for terminally ill patients in a time of suffering and sorrow. One such way is through Hospice. Hospice is a program of modern, palliative (pain and symptom control) medicine. Hospice assists patients and families who are living with terminal illness. Hospice recognizes there is value to life that is lived during the process of dying. Hospice clinicians know from direct experience that the end of life is often not empty and bleak, but rather a full, rich and deeply meaningful time for patients and families. The hospice philosophy views death as a natural part of life, whether or not resulting from disease. In hospice the care of terminally ill patients does nothing to hasten or postpone death (Hospice Is a Far Better Alternative in Caring for the Terminally Ill). Another way of caring for terminally ill patients is through terminal sedation. Terminal sedation also known as, “palliative sedation,” “Continuous deep sedation,” or “primary deep continuous sedation” (Terminal Sedation: Pulling the Sheet over Our Eyes). In recent years, sedation has become more popular for end of life care. It allows the morals that doctors hold high, such as being the healers of our world, to be respected. Terminal sedation may end pain, but some think it ends life as well. It immediately ends the possibility for social interaction. Social interaction is one thing that separates life from death. Human communication is one thing we as human beings thrive on and live for. When that ends, we end. The main reason for sedation is that patients are asking for relief from their pain, not their biological life. Thus, the focus of consent is on avoiding pain, but it in the end it should be focused on causing death. Usually sedation is used only when the patient is at the end of the downhill course of a terminal illness, and only when the patient’s pain has become extreme and other measures are no longer effective. There are no safeguards built into sedation as a medical practice. For example, there is no waiting periods, no oral consents is needed, nor any written consents (Terminal Sedation: Pulling the Sheet over Our Eyes). Yet another way to define terminal sedation is, “the intentional lowering of consciousness of a patient in the last phase of life.” Sedation is lowering the patients consciousness, so that the pain goes away until they die. This in ethical standards is allowable, but PAS isn’t? Those who believe assisted suicide should be legalized do not actually want people to die. They want to improve care at the end of life and these options should be one part of it.

There are only a few reports focusing on the patient's concerns and desires about euthanasia and PAS. Those that are published have revealed that depression, particularly the sense of hopelessness rather than pain, is the primary factor motivating patients to consider euthanasia (in which a doctor administers the lethal drug) or PAS (in which the patient himself takes the lethal drug prescribed by the physician) (Patients' Perceptions of Physician-Assisted Suicide). A survey consisting of multiple interviews with terminally ill patients that desire euthanasia or PAS tend not to be motivated by pain. Only 22 percent of patients that died between 1998 and 2009 by assisted suicide in Oregon were in pain or afraid of being in pain, according to their doctors (Ezekiel, Emanuel J.) In a study of 988 patients with a terminal illness 60.2 percent supported euthanasia or physician assisted suicide in hypothetical situations. Only 10.6 percent reported considering it for themselves (Cope, Diane) Hopelessness is a common feeling with terminally ill patients. When they can no longer care for themselves, they feel a sense of hopelessness. Before passing this act one of the main concerns, that the public voiced, was that terminally ill patients would flock to Oregon to participate in PAS. Over the years, we have seen that this is not the case. Since passing legalization of PAS in 1997, only 596 people have chosen to participate. 59 of which were in 2009 alone (Death with Dignity National Center) (Ezekiel, Emanuel J.). The prescription that is most commonly used for those wishing to participate in PAS is for barbiturates. A drug that depresses the central nervous system, causing sedation, thus killing the user in their sleep (Assisted Suicide).

Evaluating Outcomes:

Though there are still many issues surrounding the topic of PAS. There is fear that legalizing PAS across the nation would desensitize Americans to death. A recent article in the New Yorker pointed that out, “Patients had known, for some time, that they had a terminal condition. Yet they, along with their families and doctors, were unprepared for the final stage.” (Gawande). Death is something that is guaranteed to every living being on earth. It is natural and does not have to be thought of in such a taboo way. Being less sensitive to death would allow a person the freedom to openly voice and plan, how they wish to spend their final days. There is also fear that legalizing PAS would cause a “slippery slope.” One that would eventually lead to the targeting and murder of poor, disabled and elderly people (Muller, Martien T). One thing that is becoming clear is the rights of the disabled and sanctity of life. Societies growing acceptance of concepts such as “mercy killing” and euthanasia is creating a moral atmosphere in which the killing of innocent people is being not just tolerated but extolled (O'Neill, Terry). Some may think if brain activity isn’t present than it is morally okay to kill a person. Under common law the killing of a person with a heart beat is considered murder, brain activity doesn’t matter (Scheb, John M). Killing a disabled person is seen as unmoral, it’s their lives not ours so they should have the choice to die when they want. If they have the inability to make a choice to die then let them (mentally disabled) live. Though, in some instances the mentally disabled don’t get to decide life or death. In an unforeseen event Maurice and Belva Baulne chose to kill Reese, their mentally handicapped son. According to authorities the couple justified the killing on the grounds they could no longer properly care for their son. Incidences like these since PAS was legalized in Oregon have not seemed to change. Since this has not been the case thus far in Oregon, it seems highly unlikely that it would be an issue in other states. The Death with Dignity act has not been abused by any means. PAS is something that a terminally ill person may request, but it is not something that a physician will openly offer to a patient as an option. “Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others.” (Gawande). In the past few years American medicine has grown leaps and bounds. As a nation we are now capable of helping people live for years fighting terminal illnesses, but this is not usually a pain free fight. “In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions.” (Gawande). In the end it is up to each individual person how long they wish to fight and how they wish to spend their last days. The law should not be able to dictate when a person has the right to give up their own fight for life.

Summary:

A 2007 nationwide poll has shown that 82% of Americans would support a well crafted Death with Dignity act (Death with Dignity National Center).  Physician assisted suicide is currently legal in The Netherlands, Belgium, Luxemburg and Switzerland. But America, Japan, South Africa and the United Kingdom are currently torn between legalizing PAS and keeping it illegal (Assisted Suicide Laws). In America there are currently three states that have legalized physician assisted suicide, Oregon, Washington and Montana. Today there are many states in the process of implementing their own Death with Dignity acts. Some of these states include Maine and Vermont (Death with Dignity National Center). Years after implementing the Death with Dignity Act in Oregon many views of PAS have been altered, before it could have been seen as a death sentence for many terminally ill patients. Today it can be seen as a mere option for those with the intolerable pain of a terminal illness. It is a way to escape the terrible pain they may endure on the path to death. The structure and support they have implemented in maintaining PAS in Oregon has proven to work well. It is a comfort to know that, if anyone was ever diagnosed with a terminal illness, they will have the option to omit themselves from enduring pain, and will be allowed a peaceful passing when it is their own time to do so. The government should not be able to choose when and how we die. In time of pain and suffering we should have the right to choose. Though, through research we can see many don’t attempt euthanasia or PAS that is why a section out of a New York Times articles states “Instead of attempting to legalize physician-assisted suicide, we should focus our energies on what really matters: improving care for the dying — ensuring that all patients can openly talk with their physicians and families about their wishes and have access to high-quality palliative or hospice care before they suffer needless medical procedures. The appeal of physician-assisted suicide is based on a fantasy. The real goal should be a good death for all dying patients” (Ezekiel, Emanuel J.). This is a powerful statement, not just the terminally ill should be comforted in the time of death. Every living being should be comforted and cared for while dying. As we can see through this evaluation there were many negative views displayed towards the implementation of PAS. In more recent years, after PAS has been implemented as law many have changed their views and accepted the omitting of life due to pain and suffering. ‘Death with Dignity Act’ will always have ethical and moral pros and cons and will be a constant battleground in medical ethics. This policy was implemented very affectively and the interventions I should recommend I could not come up with due to the very thorough implementation the policy went through. After the implementation of PAS in Oregon our views of the subject have differed greatly from person to person. Many people support PAS and many also disagree with it. That is why so many of us are anticipating hearing much more on this topic in the coming years.

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