Euthanasia and Physician-Assisted Suicide

Module 9: Euthanasia

Reading:

Schwartz and Estrin, “In Oregon, Choosing Death over Suffering” (included in this module)

Lee, “Life, Liberty and the Right to Die” (included in this module)

Brock in Steinbock, “Voluntary Active Euthanasia,” pp. 441-454.

Arras in Steinbock, “Physician-Assisted Suicide,” pp. 455-461.

Battin in Steinbock, “Euthanasia,” pp. 467-483.

Overview

In 1994 Oregon became the first state in the U.S. to legalize physician-assisted suicide. After three years of legal challenges, the Oregon Death with Dignity Act became law. Residents of the state of Oregon who are terminally ill and within six months of imminent death (in the professional judgment of two physicians), competent of mind and who are in unbearable pain and suffering (by their own estimate) may request life-ending medication from their physician.

The newspaper article by John Schwartz and James Estrin tells the story of Arthur Wilson, 86 a World War II and Korean War veteran who has been diagnosed with a terminal illness. Wilson requested and received the lethal dose of medications, according to the Oregon law. His story is interesting: Wilson estimates that there is less than a 50 percent chance that he will ever use the medication; it’s that having the medication gives him a choice, a sense of control over his situation.

The core question in this module is this: Should terminally-ill, competent patients have the right to choose the circumstances of their death?

In the years immediately following passage of the legislation in Oregon, there was much fear-mongering:

· We can’t allow physicians to prescribe life-ending medication to terminally-ill patients because if they start prescribing the medication to terminally-ill patients they will start killing healthy patients, perhaps some against their will.

· People who are merely depressed may seek the “right” to die.

· The law will weaken physicians’ commitment to provide optimal care for dying patients.

· There will be widespread abuses, particularly with the nation’s poor and under insured.

In the 16 years since the Oregon Death with Dignity Act has been implemented, none of these fears have been realized. In fact, one of the biggest surprises since the legislation has been implemented has been the small number of patients who make use of the life-ending medication. Please allow me to quote the Oregon Health Department’s 2012 Annual Report on the Death with Dignity.

Begin Quote

Written into Death with Dignity laws is the requirement the state’s Health Department must issue annual reports of information collected during the medication request process.

Oregon’s Public Health Division recently issued their 15th annual report, and consistent with all previous years, the data continue to show the law works the way it’s intended: rarely used, but providing comfort to countless individuals who know they have options at the end of their lives.

Some quick facts about the usage of Oregon’s law in 2012:

· 77 people hastened their deaths under the Oregon law.

· This accounts for 0.2% of all deaths in Oregon.

· The top three concerns people expressed to their doctors when requesting the medication were centered around wanting control over their final days.

· Of the end-of-life concerns expressed, the least common was “financial implications of treatment.”

The numbers also show people who request the medication under Oregon’s law are receiving high quality end-of-life care:

· 97% of the people who died using Oregon’s law in 2012 were enrolled in hospice. (By way of comparison, the National Hospice and Palliative Care Organization estimates 45% of deaths in the US are under the care of hospice.)

· Over 97% of the people who used the law died at home.

These 15 years of statistics reiterate the facts about how Death with Dignity laws work and refute all of the opponents’ fear mongering assertions. In fact, the data have been so consistent over the years, this report was published without any fanfare and attracted very little media attention. The same ol’ story, it seems, is too boring to be noticed. That’s unfortunate when people who disagree with a person’s right to decide the manner and timing of his or her own death will continue to pitch the same myths to make their case.

End Quote

In the readings from your textbook Dan Brock argues from a utilitarian perspective that active euthanasia has more pros than cons. John Arras offers a somewhat dated critique of physician-assisted suicide. (The article was published in 1997 when the Oregon Death with Dignity Act was first implemented.) In the final reading for this module, Margaret Battin compares attitudes on end-of-life practices of people in three countries: the U.S., Germany and the Netherlands.

Objectives

By the end of this unit, I will be able to:

· Discuss the central features of the Oregon Death with Dignity Act

· Assess the case of Mr. Wilson

· Evaluate arguments for and against physician-assisted suicide

· Discuss the role of self-determination in arguments for physician-assisted suicide

· Discuss the role of paternalism in arguments against physician-assisted suicide

Key Concepts

· Physician-Assisted Suicide

· Active vs. Passive Euthanasia

· Voluntary, Non-voluntary and Involuntary Euthanasia

· Fear mongering as a logical fallacy

· Principle of self-determination

· Paternalism

Review Questions

[1] State the central features of the Oregon Death with Dignity Act.

[2] It has been 16 years since the Death with Dignity Act was implemented. Conduct Internet research and list any negative consequences of the implementation of this legislation. Have any of the fear-mongering concerns come true? Is it fair to describe such concerns as “fear-mongering”?

[3] The following terms are not well defined in your textbook: active euthanasia, passive euthanasia, voluntary euthanasia, non-voluntary euthanasia and involuntary euthanasia, and physician-assisted suicide. Conduct an Internet search and define these terms.

[4] Brock lists five “good consequences” of permitting euthanasia. These may be considered arguments in support of euthanasia. They are the following: (1) the argument from self-determination, (2) the argument from reassurance, (3) argument from relief of unbearable pain and suffering, (4) the argument from mercy, and (5) the argument from the principle of humaneness. Carefully explain each of these arguments.

[5] Brock lists five “bad consequences of permitting euthanasia. Again, these may be considered arguments against permitting euthanasia. They are the following: (1) Allowing physicians to prescribe life-ending medications would undermine the very core of the practice of medicine, (2) permitting euthanasia would weaken society’s commitment to provide optimal care for patients, (3) permitting euthanasia might erode society’s support for the right of patient’s to refuse treatment, (4) allowing patients to choose may overwhelm them—additional options may make patients “worse off”, and (5) permitting euthanasia might weaken laws against homicide. Carefully explain each of these arguments.

[6] Take each argument against euthanasia. On what grounds does Brock criticize these arguments? Do you think Brock’s criticism is sound or do you think any of these arguments retain merit?

[7] Arras considers (and rejects) the argument from self-determination and the argument from mercy. On what grounds does Arras reject these arguments? Do you find his critique convincing?

[8] Arras considers three objections to PAS and euthanasia: (1) the practice is inherently immoral, (2) it’s wrong to ask physicians to kill, and (3) the practice will expand to non-terminal patients and other such abuses. Evaluate these objections in light of the 2012 Report by the Oregon Health Department. Have any of these negative consequences actually happened?

[9] Objection (2) focuses on the role of the physician in medicine. Proponents of euthanasia tend to view the physician as informing patients of their options; detractors of euthanasia tend to view the physician’s role as a healer. Which view do you find more persuasive?

[10] Battin describes differences in the structure of the delivery of health care in the U.S., Germany and the Netherlands. She notes that attitudes regarding euthanasia often stem from one’s perception of the role of the physician in the delivery of health care. Describe her findings.

Discussion Question

Describe the relevant features of the case of Author Williams. From the description in the article, Mr. Williams appears competent of mind. He is terminally ill. The sense of being in control (self-determination) is important to him. Should patients like Mr. Williams be permitted to choose how they die? Should physicians who support the practice of physician-assisted suicide being permitted to prescribe such medicine? Answer within the context of the arguments advanced by Brock and Arras. Has the implementation of the Oregon Death with Dignity Act fundamentally altered the role of the physician in the state of Oregon?

(Minimum Word Count: 500 Words)

In Oregon, Choosing Death Over Suffering

By John Schwartz and James Estrin

Arthur W. Wilson sits in his study, breathing oxygen through a nose clip and pausing frequently for the coughs that rack his body.

''I'm not suicidal,'' he said. ''I'm sane.''

Mr. Wilson, 86, has been living with the profound pain of chronic obstructive pulmonary disease for years. Now he wants to end his life -- not today, not tomorrow, but when he chooses -- under the provisions of Oregon's Death With Dignity law.

''When the time comes,'' he said, ''I'm going to swallow that bottle of Lethe and say goodbye.''

He is no stranger to death, having fought in World War II and in Korea. And he craves being in control. His house is snaked through with a clear plastic tubing system that he devised to carry his oxygen from room to room without having to drag a tank around behind him.

He does not seem, in other words, to be the depressed, languishing patient many might expect to see applying for the Oregon program.

The state's law allows adults with terminal diseases who are likely to die within six months to obtain lethal doses of drugs from their doctors. In the six years since it went into effect, surprises have been common, including the small number of people who have sought lethal drugs under the law and the even smaller number of people who have actually used them. In surveys and conversations with counselors, many patients say that what they want most is a choice about how their lives will end, a finger on the remote control, as it were.

Last week, the United States Court of Appeals for the Ninth Circuit upheld Oregon's law, ruling that Attorney General John Ashcroft had overstepped his authority in trying to punish doctors who prescribed suicide drugs under the law.

And while there is still strong opposition around the country to laws like Oregon's, support within the state has grown over the years. Oregon voters passed the law in two separate referendums. Even some former opponents say the widespread abuses predicted by some have not emerged. And studies are helping researchers and policymakers understand how it really works in practice.

Perhaps the most surprising thing to emerge from Oregon is how rarely the law has actually been used.

''We estimate that one out of a hundred individuals who begin the process of asking about assisted suicide will carry it out,'' said Ann Jackson, executive director of the Oregon Hospice Association.

Since 1997, 171 patients with terminal illnesses have legally taken their own lives using lethal medication, compared with 53,544 Oregonians with the same diseases who died from other causes during that time, according to figures released by the Oregon Department of Health Services in March.

More than 100 people begin the process of requesting the drugs in a typical year. Doctors wrote 67 prescriptions for the drugs in 2003, up from 24 in 1998. Forty-two patients died under the law in 2003 compared with 16 in 1998.

Many patients say they want to have the option to end their lives if the pain becomes unbearable or if they are sliding into incompetence while still thinking clearly.

''I'd say it's less than 50-50 that I'd ever do this thing,'' said Don James, a retired school administrator with advanced prostate cancer who has not yet received his pills.

A Desire to Be in Control

A second surprise has been the kind of people who use the law. They are not so much depressed as determined, said Linda Ganzini, a professor of psychiatry at Oregon Health Sciences University. She led a recent survey of 35 doctors who had received requests for suicide drugs. The doctors described the patients as ''feisty'' and ''unwavering.''

A third lesson is that for most of those who seek assisted suicide, the greatest concern appears not to be fear of pain but fear of losing autonomy, which is cited by 87 percent of the people who have taken their lives with the drugs. Only 22 percent of the patients listed fear of inadequate pain control as an end-of-life concern, perhaps a sign that pain management has improved over the years.

And though opponents of the law argued that patients would feel pressured by families and even insurers to end their lives early out of financial concerns, so far concerns of being a burden to family have been cited by 36 percent of patients, and financial concerns by just 2 percent. The surveys show that the standard version of health care for terminally ill patients might not be what these patients are looking for, Dr. Ganzini said. The standard version of care says, in effect, ''we're going to take care of you,'' she said. But ''for them, the real problem is other people taking care of you.''

Ms. Jackson said the surveys were changing the hospice association's practices.

In 1994, the group opposed the Death With Dignity law. Now the hospices work directly with programs like Compassion in Dying, a group that is involved in 75 percent of Oregon's assisted suicides. Thanks to the surveys of patients seeking assisted suicide, Ms. Jackson said, her organization learned that half the people who rejected hospice care did so because ''they thought that hospice was condescending or arrogant.''

Now the hospices fit their treatments to patients who seek assisted suicide and emphasize that their wishes will be respected, she said.

Opponents of the Oregon law like Dr. Kenneth Stevens, chairman of the department of radiation oncology at the Oregon Health and Science University in Portland, say it violates the fundamental tenet of medicine. Dr. Stevens argues that doctors should not assist in suicides because to do so is incompatible with the doctor's role as healer.

''I went into medicine to help people,'' he said. ''I didn't go into medicine to give people a prescription for them to die.''

Dr. Stevens heads an organization, Physicians for Compassionate Care, that opposes assisted suicide and the Oregon law. Members of his group, he said, tend to be ''people of faith,'' who believe that assisted suicide violates their religious principles. But they base their opposition to the law on moral and ethical grounds, arguing that it leads down a slippery slope toward euthanasia and patient abuses.

He recalled the struggle of his wife, who died of cancer in 1982. In the weeks before she died, he said, her doctor offered her an ''extra-large prescription'' for painkillers.

''As I helped her into the car, she said, 'He wants me to kill myself,''' Dr. Stevens recalled. ''It just devastated her that her doctor, her trusted doctor, subtly suggested that.''

Others who initially opposed the law, like the hospice group, say they have learned to live with it. Michael Bailey, for example, took out a loan in 1994 to fight the Death With Dignity act. His daughter has Down syndrome, and he said that at the time he could see a straight line between voluntary assisted suicide and forced euthanasia for the handicapped.

Now Mr. Bailey says he has not seen any abuses. ''I don't see that there's ever been a scandal,'' he said, ''and the numbers are not huge.'' Still, he does not support the law. ''If it was up to me, I'd say no, but I don't think there's any great human rights crisis here,'' he said.

Support for the law crosses ideological lines, said Nicholas van Aelstyn, a lawyer in San Francisco who works with Compassion in Dying. Some commentators have characterized the movement as a liberal cause, but ''to most of the people exercising it, it's a libertarian issue,'' he said. ''Many of our clients are die-hard Republicans who don't want government interfering in their lives.''

That certainly describes Mr. Wilson, who calls himself a ''staunch conservative'' and says Mr. Ashcroft is ''dead wrong'' about the Oregon law.

The support for the law in Oregon, Mr. James said, reflects the pioneer spirit that flows from the wagon trains that brought the early settlers. ''They were pretty well-educated, family-oriented people willing to hack a new life out of this wilderness,'' he said. ''Pretty independent folks.''

Those who drafted the Death With Dignity Act say they did not try to come up with a political document that would warm the heart of Jack Kevorkian, or that would permit euthanasia, which is repugnant to a significant portion of the population. Instead, they say, they carefully drew up a law that they believed would gain support of everyone except the most determined opponents, and that was loaded with safeguards against abuse.

Doctors have long made lethal doses of drugs available to patients inclined to end their struggle against disease, said Eli Stutsman, president of the board of the Death With Dignity National Center.

''We took something that was already happening, and we wrote a law around it,'' he said.

Opponents had argued that Oregon would become a magnet for people seeking suicide, so the law's provisions were restricted to the state's residents.

The law also sets a high barrier to getting the life-ending medications, giving patients the chance to change their mind up to the last moment. A patient must make two oral requests for the drugs and one written request after a 15-day waiting period. Two doctors must determine that the patient has less than six months to live, a doctor must decide that the patient is capable of making independent decisions about health care and the doctor has to describe to the patient alternatives like hospice care.

The law also requires that the drugs be self-administered by the patient, rather than given by a doctor or family member, to avoid involuntary euthanasia. The death certificate, under the law, must state the cause of death as the underlying disease, not suicide.

That provision pleases Mr. James.

''I don't like the word 'suicide,''' he said, because ''if I'm really on a path, the natural path'' toward death, and ''just hastening it a little bit, I don't call that suicide.''

Mr. Wilson's family supports him in his wishes, although his wife, Viola, says she is against the general idea.

''This is his thing, not mine,'' she said. ''It's not the way I'd go.''

Her views flow from her religious beliefs, she said.

''I'm inclined to think that I have a purpose in life until I go,'' she said. ''God has a plan for me, and I'm here until he says it's time to go.''

She said she liked her husband's idea of having family members gather in a kind of living wake, however.

''That would be fine,'' she said. ''You should celebrate the life instead of worry about the death.''

A Last Goodbye

Although the idea of an end-of-life celebration strikes some people as unseemly or exhibitionist for a most private act, many patients say it is natural to want to bring family together for a last goodbye. Most patients call for such a gathering, although relatively few take the poison in the presence of their families.

Barbara Coombs Lee, the president of Compassion in Dying Federation, said she saw the suicides not as ''an impulse to self destruction,'' but as ''an impulse to self preservation -- preservation of the self I cherish.''

That point of view clearly grates on Dr. Stevens. Although he said he did not want to ''put people down or label people,'' he added, ''the 'P' word is not 'pain.' The 'P' word is 'pride.''' He explained, ''Rather than being death with dignity, it's death with vanity.''

But Dr. Marcia Angell, a former executive editor of The New England Journal of Medicine and a supporter of doctor-assisted suicide, said: ''He can call it vanity. Somebody else might call it admirable independence.''

If anything, Dr. Angell said, the Oregon law may be too restrictive and may not reach everyone who could benefit from it.

''I am concerned that so few people are requesting it,'' she said. ''It seems to me that more would do it. The purpose of a law is to be used, not to sit there on the books.''

Mr. Stutsman, one of the law's authors, said it helped people who never end up holding a cup of barbiturate solution in their hands.

''They get the comfort of knowing that the Oregon Death With Dignity Act is there if they need it,'' he said. Although no state has passed its own version of the act, ''Oregon is leading the national debate,'' he said.

Compassion in Dying claims that the Oregon law prevents violent suicides and the pain such deaths cause families. The patients say, however, that to some extent, the 10-year furor over the law is academic; it is not so hard to die, and people do it around the world without the benefit of laws like that passed by the Oregon Legislature.

Mr. James, for example, said, ''If it gets too bad, I might just stop eating,'' and refers jokingly to his ''Ashcroft kit,'' a sturdy plastic bag and a roll of duct tape that he could use to asphyxiate himself. But, he added, that would be illegal, and ''I just think that's bad karma to do it that way.''

Other patients say they know a good death from a bad death, and know which kind they prefer. Lovelle Svart, a retired newspaper librarian, said she recently witnessed a horrifying auto accident on the highway.

''Not that way.'' she recalled saying to herself. ''Not the way I want to go.''

Life, Liberty and the Right to Die

By Barbara Coombs Lee

Civil and human rights movements often build slowly and then appear to gain acceptance suddenly when support reaches a tipping point. Marriage equality has followed this path.

Now momentum is building for the Death with Dignity movement to enable the medical practice of aid in dying.

In 1994, 51% of Oregon voters approved a ballot measure I co-authored. Oregon's Death with Dignity Act was the nation's first to set out guidelines and safeguards for mentally competent, terminally ill patients to obtain a prescription for medication to end their life in a humane and dignified manner. Three years later, 60% of Oregon voters rejected the legislature's attempt to rescind the law.

It was 14 years before a second state approved a similar law. In 2008, 59% of Washington voters voted to follow Oregon's lead.

Just over one year later, Montana became the third state where qualified patients may obtain medication for peaceful dying. The Montana Supreme Court ruled in Compassion & Choices' landmark case Baxter v. Montana, that medical aid in dying follows Montana public policy on patient decision-making. Three months later, a Binder Research poll showed Montana voters favored "allowing dying patients in severe distress to make their own end-of-life choice to receive a prescription for life-ending medication" by a 36-point margin (60% support vs. 24% oppose). This strong support included Republican voters by an 18-point margin (53% vs. 35%).

Buried by the 2012 presidential election coverage was the narrow defeat (51%/49%) of a Massachusetts Death with Dignity initiative. Aid-in-dying opponents won by outspending supporters nearly 5-1 in a misinformation ad blitz during the campaign's final days. Opponents may have won that battle – but they are losing the war. Today support for aid-in-dying legislation is growing.

In February, the New Jersey Assembly Health & Human Services Committee approved its own Death with Dignity bill by a 7-2 vote.

One week later, the Vermont Senate approved an aid-in-dying bill. If the Vermont House passes a bill as expected, the governor has pledged to sign it.

Last month the Montana House, in a fierce fight to buck the trend and gut the Baxter v. Montana decision, approved a bill to imprison doctors up to 10 years for providing aid-in-dying. Widely seen as a harsh government intrusion, most Montanans oppose the bill.

Lawmakers are resisting the anti-aid-in-dying lobby and responding to the views of their constituents. National and state polls consistently show most people want government to allow patients who suffer in their dying to have choices. A national poll last year by Republican pollster Frank Luntz showed 84% agree that: "How a terminally ill person chooses to end his/her life should be an individual decision and not a government decision."

Some question the need for aid-in-dying laws, since few people (1 in 500) in Oregon die with prescribed medication. But many more (1 in 6) consider the option and many complete the eligibility process and never ingest the medication. Thousands achieve comfort and peace of mind knowing they have choices. Fifteen years of experience since the Oregon aid-in-dying law took effect in 1998 reveals no evidence of abuse, coercion or negative impact on hospice care. Aid in dying is only for people dying of cancer, ALS or other fatal illness and is entirely voluntary for both patients and physicians.

As a nurse and physician assistant for 25 years, I treated terminally ill patients and heard their pleas. Patients need support for their values and choices. Doctors need assurance the law allows them to honor their patients' wishes.

We all expect to live with dignity. And we all deserve to die with dignity, too.