Physician-Assisted Suicide — Oregon and Beyond
http://www.100md.com
《新英格兰医药杂志》
In February, the U.S. Supreme Court agreed to consider the legality of the Bush administration's effort to outlaw physician-assisted suicide in Oregon, raising the possibility that a ruling by the Court during its next term could effectively invalidate the controversial Oregon law known as the Death with Dignity Act. With the events leading to the death of Terri Schiavo focusing national attention on end-of-life decisions, the Court's acceptance of the case formerly known as Oregon v. Ashcroft is likely to heat up the public debate on assisted suicide. The justices will hear oral arguments in the case, now renamed Oregon v. Gonzales, soon after starting a new term next October. A decision is expected by July 2006. Whatever the future of the Oregon law, the state's seven years of experience with physician-assisted suicide have greatly influenced thinking about end-of-life issues and the practice of assisted suicide, both in the United States and elsewhere. This year, lawmakers in California and Vermont and in Britian are considering bills modeled on the Oregon law.
The case now headed for the Supreme Court began in 2001, when Oregon's attorney general, along with a physician, a pharmacist, and several terminally ill state residents, sued to block the Justice Department from punishing Oregon doctors and pharmacists for providing lethal medications to terminally ill patients who wished to end their lives. In May 2004, the U.S. Court of Appeals for the Ninth Circuit in San Francisco ruled in favor of the plaintiffs, stating that drug-enforcement officials could not use the federal Controlled Substances Act to penalize Oregon health care professionals, provided that they had followed the requirements specified in the assisted-suicide law. This past November, on the day he announced his resignation as attorney general, John Ashcroft appealed that decision to the Supreme Court.
In the past, the high court has allowed each state to determine the legal status of suicide. In a pair of 1997 decisions, the Supreme Court upheld laws in two states prohibiting physician-assisted suicide, but it left states free to legalize the practice. None except Oregon have done so. Thirty-eight states have laws that make it a crime to assist in a suicide, and several others treat such an act as a crime on the basis of their common law (precedent created by previously decided cases). Three states — North Carolina, Utah, and Wyoming — abolished the common law of crimes and have no statutes criminalizing assisted suicide. Virginia imposes civil but not criminal sanctions on anyone who assists in a suicide. The Ohio Supreme Court ruled in 1996 that assisted suicide is not a crime, although the state does not condone it.
In March, epidemiologists with Oregon's Department of Human Services issued their seventh annual report on state residents who have availed themselves of the Death with Dignity Act to end their lives. To use the law, a patient must be older than 17 years of age, capable of making and communicating health care decisions, and terminally ill with a life expectancy of less than 6 months. The patient's request for assisted suicide must be communicated to a doctor both orally and in writing, and both the prescribing physician and a consulting physician must confirm the diagnosis and prognosis as well as agree that the patient is capable of making an informed decision and is not clinically depressed. If either doctor is uncertain about the patient's mental competence, the patient must be referred for a psychiatric or psychological evaluation. People who are given a prescription for lethal medications must be able to take them orally; family members, friends, doctors, and other health care workers are forbidden to administer the drugs.
Oregon's seven years of experience with this law have been, for the most part, reassuring: medical and legal safeguards established during implementation appear to have prevented abuse, and most patients have had the expected outcome. Between 1998 and 2004, Oregon physicians wrote 326 prescriptions for drugs to be used in assisted suicide, and 208 people ended their lives by taking the drugs. In the years since legalization, the number of Oregonians hastening death in this way has increased, but it remains a tiny fraction of all terminally ill patients. According to the Oregon Department of Human Services, physician-assisted suicide was the cause of 37 deaths in 2004, about one eighth of 1 percent of all deaths in the state. Most frequently in such cases, the patient either drinks 10 g of liquid pentobarbital or swallows the powder from 9 to 10 g of secobarbital capsules (dissolved in water or applesauce). Patients are instructed to take an antinausea medication about an hour before swallowing the barbiturate. Despite this precaution, there have been some cases of partial regurgitation of the sedative, including a few in which the patients vomited one third to one half of the dose. However, in all cases but one for which information is available, the patients became unconscious — usually within a few minutes after taking the medication — and remained so until they died. The median time from ingestion to death was 25 minutes, but some patients survived for hours, including at least 17 who lived for more than 4 hours, 1 of them surviving for 37 hours and another for 48 hours. Once a patient swallows the prescribed dose, it is illegal to take any additional measure to hasten death. There have been no reported cases in which emergency medical services were summoned after a patient took the medication.
Earlier this year, in the first such case in Oregon since the law went into effect, a terminally ill patient apparently ingested the full prescribed dose of medication but did not die; instead, he awoke from a coma almost three days later and lived for two more weeks before dying of lung cancer. David E. Prueitt, 42, reportedly swallowed about 10 g of secobarbital powder mixed with water, applesauce, cinnamon, and a small amount of a sweet-tasting laxative. His wife told a reporter that he woke 65 hours later and asked, "What the hell happened? Why am I not dead?"1 The Oregon Board of Pharmacy is analyzing drug residue remaining on the empty capsules and investigating other aspects of the case, such as whether the laxative might have interfered with absorption of the barbiturate.
The law has not had the dire social consequences that some opponents predicted. There is no evidence that it has been used to coerce elderly, poor, or depressed patients to end their lives, nor has it caused any significant migration of terminally ill people to Oregon. As compared with Oregonians who died naturally from similar diseases in 2004, those who died by means of physician-assisted suicide tended to be younger (median age, 64 vs. 76 years), more highly educated, and more likely to have been divorced or never to have married. Seventy-eight percent had cancer. However, in the period from 1998 to 2004, the rates of assisted suicide were higher among people with amyotrophic lateral sclerosis (25 per 1000) and AIDS (23 per 1000) than among people with cancer (4 per 1000).
Only 2 of the 208 patients who died by means of lethal medication were uninsured, and 86 percent were enrolled in hospice care. Most died at home; only one died in an acute care hospital. The most frequent reasons for choosing assisted suicide, mentioned by more than 80 percent of patients, were loss of autonomy, loss of dignity, and loss of the ability to enjoy life. Thirty-six percent expressed concern about being a burden to family or caregivers; 22 percent cited inadequate pain control. Only 3 percent mentioned financial concerns. Researchers who have analyzed the personalities of patients choosing assisted suicide have found them to be exceptionally eager to control their own lives and remain independent. "I don't want to die not knowing if it's day or night, not knowing anybody in my family," Richard Holmes, one of the original plaintiffs in Oregon v. Ashcroft, told me in 2001. "I want to know what's going on and do it myself if I'm going to do it: say `Adios.'" Holmes had obtained a lethal dose of barbiturates from a doctor, but like about 36 percent of the people who have done so under the law, he never used it; he died of cancer in September 2002.
Although relatively few terminally ill patients in Oregon actually make use of the law, recent findings indicate that many more consider doing so. Medical ethicist Susan W. Tolle and colleagues interviewed the next of kin of 1384 Oregonians who died of natural causes. A total of 236 respondents (17 percent) reported that their sick relative had mentioned considering assisted suicide. However, only 25 said their relative had formally requested a prescription for lethal medication. In 17 cases, respondents said the doctor refused the request or dissuaded the patient.2 "It is on the minds of more patients and families than physicians have any idea of," Tolle said.
There is suggestive evidence that the widely publicized debate about the assisted-suicide law and its enactment contributed to overall improvements in end-of-life care in Oregon. According to Tolle, Oregon has the lowest rate of in-hospital deaths of any state. Hospice admissions increased during the late 1990s, and the state adopted a standardized physician's order form for recording patients' wishes with regard to the use or limitation of life-sustaining treatment. Among Oregon physicians surveyed in 1999, 76 percent of those who cared for terminally ill patients reported having worked to improve their knowledge of pain treatment.3
Yet some Oregon physicians remain adamantly opposed to the law, maintaining that a patient's wish to hasten death may reflect unrecognized, treatable depression or a lack of support for other options. "When a patient says, `I don't want to be a burden,' it may really be a question, `Am I a burden?'" noted William L. Toffler, a professor of family medicine at Oregon Health and Sciences University and the national director of Physicians for Compassionate Care, a group that opposes assisted suicide.
Toffler made this comment in testimony before members of the House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, who traveled from the United Kingdom to Oregon this past December to learn about how the law has worked. The bill that the House of Lords has been considering, broadly modeled on the Oregon law, would legalize assisted suicide and euthanasia under specific circumstances, for patients who are terminally ill, mentally competent, and suffering unbearably. The committee was charged with investigating whether current British laws outlawing such practices should be changed.
British opinion on assisted suicide has shifted during the past decade, according to Mark Slattery of the Voluntary Euthanasia Society in England and Wales. Cases in which seriously ill British patients traveled to Switzerland to obtain lethal medication in order to end their lives have been widely reported in the media. In a nationally representative poll conducted last September, 82 percent of respondents said terminally ill patients who are suffering unbearably should be allowed to receive medical help to die, if they want it. The British Medical Association, the nation's largest physicians' organization, opposes the Assisted Dying for the Terminally Ill Bill, but the Royal College of Physicians and the Royal College of General Practitioners recently dropped their opposition. The bill, which lacks government backing, is considered unlikely to pass this session. Earlier this month, the select committee issued its report, including a recommendation that "a clear distinction should be drawn in any future bill between assisted suicide and voluntary euthanasia in order to provide [Parliament] with an opportunity to consider carefully these two courses of action, and the different considerations which apply to them."4
Meanwhile, two California lawmakers held public hearings this past winter on another bill, closely patterned on the Oregon law, that they introduced in the state legislature in February. Democratic assembly members Patty Berg of Sebastopol and Lloyd Levine of Van Nuys brought witnesses from Oregon to the hearings in California to address concerns about how legalizing assisted suicide in this state might affect people with disabilities and how physicians evaluate the emotional state and mental competence of a terminally ill patient who requests lethal medication. A 1992 initiative to legalize euthanasia in California was voted down, and an assisted-suicide bill introduced in 1999 failed to pass the legislature, but Levine said he believes that the generally reassuring experience with the Oregon law has increased the chances of enacting a similar statute in California. "I would say this is not suicide," he said. "This is giving people dignity and control at the end of their lives." The state has already taken a number of measures to improve end-of-life care, including requiring that medical students be trained in pain management and that practicing physicians obtain continuing education in pain treatment and palliative care.
But Oregon's successful implementation of its assisted-suicide law might not be easily replicated in other states with more socioeconomically diverse populations and less inclusive health care programs, cautioned Joanne Lynn, a senior researcher with the RAND Corporation and director of the Washington Home Center for Palliative Care Studies in Washington, D.C. "There isn't a huge demand for assisted suicide in good care systems, but there could be a huge demand in much less adequate care systems," Lynn said.
Psychiatrist Linda Ganzini of Oregon Health and Sciences University agrees that her state's high-quality system of palliative care is the factor most responsible for keeping the number of assisted-suicide cases low. "Your safety net is your end-of-life care and your hospice care," she said. "It's not the safeguards that you build into the law."
Source Information
Dr. Okie is a contributing editor of the Journal.
References
Colburn D. Why am I not dead? The Oregonian. March 4, 2005:A01.
Tolle SW, Tilden VR, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA, Delorit MA. Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA 2001;285:2363-2369.
House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill. Volume I: Report. HL Paper 86-I.(Susan Okie, M.D.)
The case now headed for the Supreme Court began in 2001, when Oregon's attorney general, along with a physician, a pharmacist, and several terminally ill state residents, sued to block the Justice Department from punishing Oregon doctors and pharmacists for providing lethal medications to terminally ill patients who wished to end their lives. In May 2004, the U.S. Court of Appeals for the Ninth Circuit in San Francisco ruled in favor of the plaintiffs, stating that drug-enforcement officials could not use the federal Controlled Substances Act to penalize Oregon health care professionals, provided that they had followed the requirements specified in the assisted-suicide law. This past November, on the day he announced his resignation as attorney general, John Ashcroft appealed that decision to the Supreme Court.
In the past, the high court has allowed each state to determine the legal status of suicide. In a pair of 1997 decisions, the Supreme Court upheld laws in two states prohibiting physician-assisted suicide, but it left states free to legalize the practice. None except Oregon have done so. Thirty-eight states have laws that make it a crime to assist in a suicide, and several others treat such an act as a crime on the basis of their common law (precedent created by previously decided cases). Three states — North Carolina, Utah, and Wyoming — abolished the common law of crimes and have no statutes criminalizing assisted suicide. Virginia imposes civil but not criminal sanctions on anyone who assists in a suicide. The Ohio Supreme Court ruled in 1996 that assisted suicide is not a crime, although the state does not condone it.
In March, epidemiologists with Oregon's Department of Human Services issued their seventh annual report on state residents who have availed themselves of the Death with Dignity Act to end their lives. To use the law, a patient must be older than 17 years of age, capable of making and communicating health care decisions, and terminally ill with a life expectancy of less than 6 months. The patient's request for assisted suicide must be communicated to a doctor both orally and in writing, and both the prescribing physician and a consulting physician must confirm the diagnosis and prognosis as well as agree that the patient is capable of making an informed decision and is not clinically depressed. If either doctor is uncertain about the patient's mental competence, the patient must be referred for a psychiatric or psychological evaluation. People who are given a prescription for lethal medications must be able to take them orally; family members, friends, doctors, and other health care workers are forbidden to administer the drugs.
Oregon's seven years of experience with this law have been, for the most part, reassuring: medical and legal safeguards established during implementation appear to have prevented abuse, and most patients have had the expected outcome. Between 1998 and 2004, Oregon physicians wrote 326 prescriptions for drugs to be used in assisted suicide, and 208 people ended their lives by taking the drugs. In the years since legalization, the number of Oregonians hastening death in this way has increased, but it remains a tiny fraction of all terminally ill patients. According to the Oregon Department of Human Services, physician-assisted suicide was the cause of 37 deaths in 2004, about one eighth of 1 percent of all deaths in the state. Most frequently in such cases, the patient either drinks 10 g of liquid pentobarbital or swallows the powder from 9 to 10 g of secobarbital capsules (dissolved in water or applesauce). Patients are instructed to take an antinausea medication about an hour before swallowing the barbiturate. Despite this precaution, there have been some cases of partial regurgitation of the sedative, including a few in which the patients vomited one third to one half of the dose. However, in all cases but one for which information is available, the patients became unconscious — usually within a few minutes after taking the medication — and remained so until they died. The median time from ingestion to death was 25 minutes, but some patients survived for hours, including at least 17 who lived for more than 4 hours, 1 of them surviving for 37 hours and another for 48 hours. Once a patient swallows the prescribed dose, it is illegal to take any additional measure to hasten death. There have been no reported cases in which emergency medical services were summoned after a patient took the medication.
Earlier this year, in the first such case in Oregon since the law went into effect, a terminally ill patient apparently ingested the full prescribed dose of medication but did not die; instead, he awoke from a coma almost three days later and lived for two more weeks before dying of lung cancer. David E. Prueitt, 42, reportedly swallowed about 10 g of secobarbital powder mixed with water, applesauce, cinnamon, and a small amount of a sweet-tasting laxative. His wife told a reporter that he woke 65 hours later and asked, "What the hell happened? Why am I not dead?"1 The Oregon Board of Pharmacy is analyzing drug residue remaining on the empty capsules and investigating other aspects of the case, such as whether the laxative might have interfered with absorption of the barbiturate.
The law has not had the dire social consequences that some opponents predicted. There is no evidence that it has been used to coerce elderly, poor, or depressed patients to end their lives, nor has it caused any significant migration of terminally ill people to Oregon. As compared with Oregonians who died naturally from similar diseases in 2004, those who died by means of physician-assisted suicide tended to be younger (median age, 64 vs. 76 years), more highly educated, and more likely to have been divorced or never to have married. Seventy-eight percent had cancer. However, in the period from 1998 to 2004, the rates of assisted suicide were higher among people with amyotrophic lateral sclerosis (25 per 1000) and AIDS (23 per 1000) than among people with cancer (4 per 1000).
Only 2 of the 208 patients who died by means of lethal medication were uninsured, and 86 percent were enrolled in hospice care. Most died at home; only one died in an acute care hospital. The most frequent reasons for choosing assisted suicide, mentioned by more than 80 percent of patients, were loss of autonomy, loss of dignity, and loss of the ability to enjoy life. Thirty-six percent expressed concern about being a burden to family or caregivers; 22 percent cited inadequate pain control. Only 3 percent mentioned financial concerns. Researchers who have analyzed the personalities of patients choosing assisted suicide have found them to be exceptionally eager to control their own lives and remain independent. "I don't want to die not knowing if it's day or night, not knowing anybody in my family," Richard Holmes, one of the original plaintiffs in Oregon v. Ashcroft, told me in 2001. "I want to know what's going on and do it myself if I'm going to do it: say `Adios.'" Holmes had obtained a lethal dose of barbiturates from a doctor, but like about 36 percent of the people who have done so under the law, he never used it; he died of cancer in September 2002.
Although relatively few terminally ill patients in Oregon actually make use of the law, recent findings indicate that many more consider doing so. Medical ethicist Susan W. Tolle and colleagues interviewed the next of kin of 1384 Oregonians who died of natural causes. A total of 236 respondents (17 percent) reported that their sick relative had mentioned considering assisted suicide. However, only 25 said their relative had formally requested a prescription for lethal medication. In 17 cases, respondents said the doctor refused the request or dissuaded the patient.2 "It is on the minds of more patients and families than physicians have any idea of," Tolle said.
There is suggestive evidence that the widely publicized debate about the assisted-suicide law and its enactment contributed to overall improvements in end-of-life care in Oregon. According to Tolle, Oregon has the lowest rate of in-hospital deaths of any state. Hospice admissions increased during the late 1990s, and the state adopted a standardized physician's order form for recording patients' wishes with regard to the use or limitation of life-sustaining treatment. Among Oregon physicians surveyed in 1999, 76 percent of those who cared for terminally ill patients reported having worked to improve their knowledge of pain treatment.3
Yet some Oregon physicians remain adamantly opposed to the law, maintaining that a patient's wish to hasten death may reflect unrecognized, treatable depression or a lack of support for other options. "When a patient says, `I don't want to be a burden,' it may really be a question, `Am I a burden?'" noted William L. Toffler, a professor of family medicine at Oregon Health and Sciences University and the national director of Physicians for Compassionate Care, a group that opposes assisted suicide.
Toffler made this comment in testimony before members of the House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill, who traveled from the United Kingdom to Oregon this past December to learn about how the law has worked. The bill that the House of Lords has been considering, broadly modeled on the Oregon law, would legalize assisted suicide and euthanasia under specific circumstances, for patients who are terminally ill, mentally competent, and suffering unbearably. The committee was charged with investigating whether current British laws outlawing such practices should be changed.
British opinion on assisted suicide has shifted during the past decade, according to Mark Slattery of the Voluntary Euthanasia Society in England and Wales. Cases in which seriously ill British patients traveled to Switzerland to obtain lethal medication in order to end their lives have been widely reported in the media. In a nationally representative poll conducted last September, 82 percent of respondents said terminally ill patients who are suffering unbearably should be allowed to receive medical help to die, if they want it. The British Medical Association, the nation's largest physicians' organization, opposes the Assisted Dying for the Terminally Ill Bill, but the Royal College of Physicians and the Royal College of General Practitioners recently dropped their opposition. The bill, which lacks government backing, is considered unlikely to pass this session. Earlier this month, the select committee issued its report, including a recommendation that "a clear distinction should be drawn in any future bill between assisted suicide and voluntary euthanasia in order to provide [Parliament] with an opportunity to consider carefully these two courses of action, and the different considerations which apply to them."4
Meanwhile, two California lawmakers held public hearings this past winter on another bill, closely patterned on the Oregon law, that they introduced in the state legislature in February. Democratic assembly members Patty Berg of Sebastopol and Lloyd Levine of Van Nuys brought witnesses from Oregon to the hearings in California to address concerns about how legalizing assisted suicide in this state might affect people with disabilities and how physicians evaluate the emotional state and mental competence of a terminally ill patient who requests lethal medication. A 1992 initiative to legalize euthanasia in California was voted down, and an assisted-suicide bill introduced in 1999 failed to pass the legislature, but Levine said he believes that the generally reassuring experience with the Oregon law has increased the chances of enacting a similar statute in California. "I would say this is not suicide," he said. "This is giving people dignity and control at the end of their lives." The state has already taken a number of measures to improve end-of-life care, including requiring that medical students be trained in pain management and that practicing physicians obtain continuing education in pain treatment and palliative care.
But Oregon's successful implementation of its assisted-suicide law might not be easily replicated in other states with more socioeconomically diverse populations and less inclusive health care programs, cautioned Joanne Lynn, a senior researcher with the RAND Corporation and director of the Washington Home Center for Palliative Care Studies in Washington, D.C. "There isn't a huge demand for assisted suicide in good care systems, but there could be a huge demand in much less adequate care systems," Lynn said.
Psychiatrist Linda Ganzini of Oregon Health and Sciences University agrees that her state's high-quality system of palliative care is the factor most responsible for keeping the number of assisted-suicide cases low. "Your safety net is your end-of-life care and your hospice care," she said. "It's not the safeguards that you build into the law."
Source Information
Dr. Okie is a contributing editor of the Journal.
References
Colburn D. Why am I not dead? The Oregonian. March 4, 2005:A01.
Tolle SW, Tilden VR, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
Ganzini L, Nelson HD, Lee MA, Kraemer DF, Schmidt TA, Delorit MA. Oregon physicians' attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA 2001;285:2363-2369.
House of Lords Select Committee on the Assisted Dying for the Terminally Ill Bill. Volume I: Report. HL Paper 86-I.(Susan Okie, M.D.)