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Living with Death in Oregon
Oregon Physicians speak about practicing medicine under the Physician Assisted Suicide Law

By Regina Doman

It has been 20 months since the citizens of Oregon voted to affirm Measure 16, which allowed physicians to prescribe a lethal dosage of drugs for patients who were certified as mentally sound, and wished to commit suicide. On February 18, 1999, the Oregon Health Association released a report stating that all was well with the new law, which “only” 15 people had invoked in order to end their own lives. According to euthanasia advocates, nothing really has changed in Oregon, except that people are free to commit suicide with the help of their doctors.

Hannah Davidson, director of Oregon Death with Dignity (ODWD), says:

We feel that the act is being implemented responsibly, in that it is rarely used. Our larger goal is to improve end-of-life care. That has happened. Fewer people are dying in hospitals; more are dying at home. There is more access to hospice.

Davidson says that Measure 16 and the discussions surrounding it “have made Oregon the best state to die in.”

But some doctors in Oregon have a different opinion, which they say is shared by a growing number of Oregonians.

Dr. Bill Toffler, an Oregon physician, says he and other health care workers have noticed a definite climate change in their practices since Measure 16 became law. “Many people no longer have the level of trust they once did in the doctor-patient relationship,” he observes.

Toffler is a member of Physicians for Compassionate Care (PCC), an organization founded by a group of Oregon physicians in January of 1995 in response to the threat of Measure 16. “We realized we had to identify and capture our once consistent ethic,” he recalls. Today the organization has 1,600 members in the US and other countries. About 1,000 of those doctors practice in Oregon.

“People contact us regularly with their concerns about the motives of their providers and the care they are or are not receiving,” Toffler reports. Usually, he says, he and his colleagues can provide advice and encouragement, or at least refer the patients to another health care provider whose approach is not so discouraging or coercive.

But Toffler says that he also knows of cases in which the people who contact PCC, or the loved ones on whose behalf they are calling, are not receiving adequate medical care. These people are being told that they are “too old,” or that their health problems will be “unnecessarily prolonged.” Toffler sees a growing danger that health care bureaucracies will deny care to certain people on the basis of strictly financial calculations.

“There is no question that the climate has changed,” he says. He recalls one woman whose oncologist told her, “You want to die, don’t you?” The doctor was gently nudging the elderly woman toward suicide, after she indicated that she might change her mind about accepting extra care.

State-funded suicide

When asked about the breakdown of trust in the doctor-patient relationship, Hannah Davidson of ODWD responds,

I’d say that people should have a discussion with their doctor if they don’t trust him. If they’re not in agreement with him, they’re not in control. Patients should feel comfortable, not stuck with their doctors.

But according to Dr. Greg Hamilton, the president of PCC, “From the beginning, physician-assisted suicide has been a ruse to usher in lethal injection—a practice which gives control to health care institutions, not the patient.” The law has stigmatized all people with terminal illnesses, argues Hamilton. Before Measure 16 was enacted, he says, “legally, being diagnosed with a terminal illness meant that you were eligible for hospice care. Now it means you are eligible for assisted suicide.”

Moreover, Hamilton continues, doctors cannot accurately predict that a person will die in six months or less. (The prospect of certain death within six months is the definition of “terminal” illness used to select candidates for legal assisted suicide under the terms of Measure 16.) However, the diagnosis that a patient’s illness is “terminal” has been used to treat a whole class of medical patients “as though their lives are not as valuable as yours or mine,” he says.

As a result, Hamilton reports, the members of PCC have become much more careful about their terminology; they do not classify any patient as “terminal.” Instead, “We say they have a serious illness which may be terminal,” he explains; “Saying otherwise can cost someone his life.”

Hannah Davidson argues that the law doesn’t stigmatize “terminal” patients, but empowers them. Asked to comment on the criticism that “terminal” patients may be deprived of adequate care, she replies:

We’ve found just the opposite. The law says that the patients have to be informed of all the other options to suicide, so the patients are more aware. The act forces this discussion with the physician, and gives the patient the control. It’s completely different from Kevorkian—the way he practices, he’s in control. He would have been arrested in Oregon as well. Self-administering suicide is the most important part of the law.

Hamilton begs to differ. “Once a state—any state—accepts assisted suicide, it becomes virtually impossible to punish any killing in the medical setting,” he says. Hamilton refers to the case of a Dr. Gallant, who authorized a lethal injection for an elderly woman who had not requested it. The Oregon Board of Health took away his medical license for six months, and in June his appeal was denied. But the prosecutor dropped the effort to prosecute him under Oregon criminal statutes, saying that he did not think he could get a conviction. Hamilton explained:

It was fully established in this court that this woman was killed without her consent. But once you accept suicide, you also end up accepting lethal injections. We could not prosecute Kevorkian here.

Davidson responded that she was not familiar enough with the case of Dr. Gallant to comment.

Conflict of interest for government?

Hamilton criticizes the state government’s own Oregon Health Plan—which, he reports:

. . . rations care for the poor and disabled. It funds assisted suicide. However, there are 150 needed services that it won’t provide, including curative treatment for some cancers. The poor and disabled are pressured by these financial arrangements. This is not the intention of their health care managers, but it is the result.

To that charge, Davidson replies:

Actually, physician-assisted suicide is part of comfort care. It’s an inexpensive procedure; it costs approximately $150. If it wasn’t covered, then poor people wouldn’t have same access.

Only two of the first fifteen suicides in Oregon were eligible for state coverage, and only one of the patients used that coverage. Davidson argues that these patients were not motivated by the pressure of unpaid medical bills, since “by the time a person gets to the point where they are eligible for assisted suicide, all other procedures are in the past.” So she concludes: “It would be a stretch to think that the government is pushing people in this direction. It’s not some sort of government conspiracy.”

Euthanasia opponents in Oregon have called attention to the fact that the state reduced the amount of government-sponsored coverage for pain medication at the same time that the coverage for physician-assisted suicide was added to the Oregon Health Plan. Although the state later doubled the coverage for pain treatments, “the amount of pain medication they will cover is still limited, which it shouldn’t be,” Dr. Toffler points out.

Still Davidson and ODWD see no cause for concern. She is unmoved by the fact that government health care officials cut back on their subsidies for pain medication. “If it’s the case I heard of, it was a complicated situation,” she claims; “a manufacturer increased the dosage of one specific kind of medication, and that caused the state to purchase less of it.” The cutback, she concludes, “wasn’t some arbitrary decision. I think it was just one case blown out of proportion.” In fact, Davidson argues that the discipline imposed on health care workers who are forced to make difficult choices about treatment of terminal illness has helped to improve the overall quality of end-of-life care.

But Hamilton takes exactly the opposite view, worrying that the quality of end-of-life care is suffering as the result of the trend toward euthanasia. As a psychiatrist, he fears that doctors who engage in assisted suicide for patients who are seriously ill often overlook an obvious diagnosis of depression—an ailment that can be successfully treated. He cites the first publicly reported case of legal assisted suicide, in which the victim had been diagnosed as depressed. Although her physician was open to assisted suicide, he judged that her depression would prevent her from making a rational decision. After her family referred her to the Compassion In Dying Federation, she was referred to a series of “activist” physicians who found her competent, and she was dead by lethal overdose in less than three weeks. Hamilton observes:

The state reports denied that depression was a factor in any of the fifteen cases—despite the fact that it was published in the newspaper and in several medical journals that this first patient was depressed. There was no accounting for the failure to effectively treat that depression.

As another example, the PCC leader cites a man in his 50s, a hospice patient with serious cancer, who came to him for help. The patient’s doctor had diagnosed his illness as terminal so that the man would be eligible for hospice care. But shortly after he started hospice care, he went into the hospital for a short procedure to drain fluid from an organ that was causing him pain. He was recovering from the procedure when the hospice nurse who was responsible for his care passed by his room and saw him. She asked him, “What are you doing here? You’re a hospice patient!” In other words, he felt that since he was terminally ill, he should not have been receiving such medical treatment. Hamilton summarizes, “This man felt that the availability of assisted suicide endangered his life—not just his medical care, but his life.”

Hamilton worries that hospice care has become capitated—that is, patients are only allotted a certain amount of medical care before they die. “I’m not saying the hospice system is promoting suicide,” he carefully explains. “I’m saying that this patient and other patients are afraid of the attitude created by this law.” He sees the same attitude surfacing among other health care workers and government agencies as well.

Offering not death, but love

What alternative can physicians and health care workers offer for patients who are contemplating suicide? Citing the psychiatrist Herbert Handon, Dr. Hamilton says, “The triad of empathy, psychotherapy, and medication successfully treats suicide tendencies in the seriously ill just like it does with anyone else.”

Hamilton declined to give the names of any patients who had come to him seeking suicide, citing doctor-patient confidentiality. “The other side—the pro-suicide people—regularly exploit their patients, and give out the names of those who have committed suicide,” he notes. He insists that patients who are thinking about suicide need help—and not only medical help. “You help them by helping them discover meaning in their life, just as we all have to find meaning in our lives,” he says. “Just because their time frame is shorter than ours doesn’t make them any different from you and me.”

Regina Doman writes from Front Royal, Virginia. Physicians for Compassionate Care can be reached at P. O. Box 6042, Portland, Oregon 97228; (503) 533-8154.

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