Physician Assisted Suicide in Oregon
as viewed by a Cancer Doctor

Parliament, British House of Lords
Committee Rm G
14 June  2005
3:30 - 4:30 pm

presentation by Kenneth R. Stevens, Jr., M.D.
Professor and Chair, Department of Radiation Oncology
Oregon Health & Science University, Portland, Oregon
Co-Founder, Physicians for Compassionate Care Education Foundation
http://www.pccef.org/

            I have been in the practice of Radiation Oncology, treating cancer patients, for 38 years in Oregon.  I have been Professor and Chair of the Department of Radiation Oncology at the only medical school in Oregon for the past 16 years.
            I have studied Oregon's assisted-suicide law since its passage in 1994.  The more I have learned, the more I realize the significant harm and danger of assisted suicide to the vulnerably ill and to society.

There has been a profound negative shift in attitude towards terminally ill patients in Oregon. The commitment to care becomes a commitment to the option of killing.
            Prior to the legalization of assisted suicide in Oregon, I and other doctors cared for our patients without regards to labels such as "terminal".  We helped patients and families make difficult decisions regarding their care.  When a patient or family chose to not continue active efforts to cure, we collectively focused all our energy and effort to help the patient live fully and comfortably until their natural death.
            Since the legalization of assisted suicide in Oregon, terminally ill and even non-terminally ill patients are considering assisted suicide.  I have had patients refuse potentially curative treatment for a localized cancer, saying, "No, I will wait until I can have assisted suicide".
            If a patient appears to be eligible for assisted suicide and receives a prescription for lethal barbiturate overdose, what is the incentive to continue to evaluate the patient and provide for their palliative care needs?
            An example of this is Michael Freeland, who was diagnosed with terminal lung cancer.  He felt devastated and said he might as well begin planning his funeral.  He had a long history of serious depression and previous suicide attempts.  While he was diagnosed with depression, given antidepressant medications, and even placed in a psychiatric hospital against his wishes by some doctors, another doctor, an assisted-suicide activist, gave this man deadly barbiturates without even a cursory psychiatric examination, and did nothing to retrieve those drugs after a county court declared him incompetent to make his own medical decisions.  The assisted suicide doctor did nothing to care for his pain and palliative care needs, but did offer to sit with him while he took the overdose.  Prior to his discharge from the mental hospital unit, a palliative care consultant wrote that Mr. Freeland probably needed attendant care at home, but providing for that additional care may be "a moot point" because he had "life-ending medication".  He was receiving poor advice and medical care because he had lethal drugs.  Once a patient has received a prescription for lethal drugs, what is the incentive for doctors and others to care for a patient and to seek to relieve their symptoms, when that patient can  take the lethal drugs at any time?  The legalization of assisted suicide results in a deterioration of caring for patients' medical needs and symptoms. 
[This case was reported at the May 2004 American Psychiatric Association scientific meeting.][1]
[Hamilton & Hamilton, Am. J. Psychiatry 2005; 162:1060-1065]

There are end-of-life care problems in Oregon.
            A national organization, "Last Acts", issued a "report card" in November 2002 to states regarding their end-of-life care.  Oregon was given a "D" grade for hospice (less than 1/3rd of dying Oregonians used hospice), and an "E" grade for palliative care programs.[2]  [Last Acts, November 18, 2002]
            After two to four years ( between June 2000 and March 2002) of assisted suicide in Oregon, there were almost twice as many dying patients in moderate or severe pain or distress, as there had been prior to Oregon's assisted suicide law being used. [3] [Fromme, Tilden, Drach, Tolle. J Palliative Med 2004;7:431-442]

Hospice care in USA is financially restricted to comfort care only.
            This means that entering hospice care in the USA is a one-way ticket. We do not have the integration of palliative care and oncology specialties that you have in the UK, so once patients sign into hospice care they are effectively signing away any radical treatments. Two weeks ago, one of my patients was referred to hospice, but the hospice personnel would not see her until she had completed the two-week long course of radiation therapy. Even though she could have benefited from hospice earlier.

Pain is not the issue.
            There is not one instance in Oregon of assisted suicide being used for actual untreatable pain. Assisted suicide is being used for psychological and social concerns.

Controlling people want assisted suicide.
            Oregon assisted-suicide patients have been described by their doctors as being fiercely independent and controlling.
            Dr. Linda Ganzini reported that Oregon's assisted suicide "patients were exceptional in the degree to which they valued control and abhorred dependence." [4] [Ganzini, Dobscha, Heintz, Press. J Palliative Med 2003;6:381-390]
            Society should always fear laws that are established by and for controlling people.  History has taught us that once such laws are established, the poor and vulnerable are discriminated against.

There are problems with "safeguards".
                Assisted suicide proponents talk about the "safeguards" with Oregon's assisted suicide law.  When persons desiring assisted suicide find themselves outside the boundaries that are written in the law's "safeguards", they want to bypass or stretch the boundaries.  This is especially true of people who have been described by their doctors as being extreme in their desire for control of their lives and death.

Oregon's assisted suicide "safeguards" are not being followed.
                With virtually every case that has come to public light, the closer one looks at individual cases, the uglier is the reality.
            The assisted suicide law provides no protection for the depressed or mentally ill.  Shockingly, only 5% of those dying from assisted suicide in 2003 and 2004 had a mental health consultation.[5], [6]  [6th& 7th Annual Reports on Oregon's DDA, for years 2003 & 2004]
            In Oregon, patients with mental disorders can receive lethal drugs to kill themselves.  Nationally, the majority of forensic psychiatrists believe that the presence of major depressive disorder should result in an automatic finding of incompetence.[7] [Ganzini et al, Am J. Psychiatry 2000;157:595-600]
            Kate Cheney was a woman in her 80s with cancer who requested assisted suicide. After a psychiatric evaluation determined that she had dementia and was not mentally capable, she and her family sought a psychologist's evaluation that felt that she was capable. This is an example of "doctor-shopping" to get a desired opinion. She finally received the prescription for lethal drugs from a Kaiser HMO doctor. [8] [The Oregonian newspaper, Oct. 17, 1999]
            Patrick Matheny[9] [The Oregonian newspaper, March 11, 1999] and Barbara Houck[10] [Washington Post newspaper, Nov. 3, 1999] were patients with motor neurone disease, who had problems swallowing and being able to self-administer the medication.  Mr. Matheny had to be "helped" by his brother-in-law because of his trouble swallowing.  Mrs. Houck had the lethal medication spoon-fed into her mouth.  Where was the self-administration in these cases?
            Determining that a person has less than six months to live (terminal) is fraught with error.  Some Oregonians who have received the prescriptions for lethal medication have lived far longer than 6 months, some for more than 2 years.
            Many doctors are writing prescriptions for lethal drugs to patients for whom they have not previously cared.  Dr Peter Rasmussen [who has reported writing prescriptions for more than 10 patients] reported that "75% of the patients who come to him regarding assisted suicide are people he has never seen before".  Regarding the "slippery slope" of assisted suicide, Dr. Rasmussen said, "I think all involved in the Oregon law must recognize that we are on a slippery slope, and we have to be careful with every step.  But just because it's a slippery slope doesn't mean we shouldn't go there." [11] [American Medical News, April 4, 2005]

There are failed assisted suicides in Oregon.
            "Why am I not dead?" was the March 4, 2005, Oregonian newspaper headline. [12]  [The Oregonian newspaper, March 4, 2005] David Prueitt, a 42-year old man with lung cancer, awoke on 2 Feb 2005, 65 hours after taking a supposedly lethal dose of barbiturate mixed in apple sauce.  He did not attempt to repeat taking lethal medication, and he died of natural causes 13 days later.  Why did he not try again?  Obviously he no longer wanted to die of assisted suicide.

There is secrecy regarding what is happening in Oregon.
            There is lack of proper oversight of Oregon's assisted suicide by the Oregon Department of Human Services.  A March 8, 2005, Oregonian newspaper editorial, in referring to the relative lack of reported complications in Oregon's assisted suicide law, stated: "But how can we be for sure?  As the Prueitt case shows, the people reporting the central facts of the [Oregon] experiment are not disinterested.  The results must be considered suspect because they may be shaded by people who, for various reasons, want things to seem fine..  The facts must be allowed to emerge through objective assessment.  This case demonstrates that Oregon's mechanism for that simply doesn't exist." [13]   [The Oregonian newspaper, March 8, 2005]
           According to the Compassion in Dying organization, about three-fourths of those dying from assisted suicide in Oregon are doing it under the direction of that organization.  That organization has a vested interest in not reporting complications or problems.

There is no real monitoring of Oregon's assisted suicides.
           When Mr. Prueitt's failed assisted suicide was made public, the Oregon Department of Human Services (DHS) publicly stated that they had "not authority to investigate individual Death with Dignity cases.  The state law authorizing physician-assisted suicide neither requires or authorizes investigations by DHS." [14] [Oregon DHS News Release, March 4, 2005]
           We are dependent on self-reporting by doctors, and in over 70% of assisted-suicide deaths in 2003 and 2004, the prescribing doctors were not there when the patients took their lethal medications, so how do they know what happened at the time of death?  5, 6 [Oregon Annual Reports for 2003 & 2004] They don't.  This information is obtained second or even third hand. The Oregon state Dept. of Human Services has commented that what they receive from doctors might be a "cock and bull story".[15]  [CD Summary, Oregon Health Division, March 16, 1999] We really do not know what is going on in Oregon.

There are financial and societal dangers, assisted suicide and euthanasia may become the only choice for some patients.
            In Oregon, for financially poor patients with cancer with a less than 5% chance of living 5 years, the OHP (Medicaid) will not pay for curative or local medical treatment services.  But they will pay for assisted suicide for such patients. [16]
[Prioritized List of Health Services, Oregon Health Plan, Oregon Health Services Commission, http://egov.oregon.gov/das/ohppr/hsc/current_prior.shtml]
            In 2003, Oregon Medicaid stopped paying for medicines for 10,000 poor Oregonians who had been on Medicaid (Oregon Health Plan).  This included patients with AIDS, bone marrow transplants, mentally ill and those with seizure-disorders.
            In December 2004, the Oregonian newspaper reported that 50,000 poor Oregonians had been cut from the Oregon Health Plan, and that the state planned to cut another 25,000 Oregonians from the plan by June 2005, to keep the state budget balanced. [17]  [The Oregonian newspaper, Dec. 1, 2004]
            These cutbacks in medical-care financial support are killing Oregonians.  It was reported in The Oregonian newspaper in December 2002 that there had been 94 mental health-related deaths because of the state cutback in mental health services for the poor.[18]  [The Oregonian newspaper, Dec. 29, 2002]
            The vulnerable financially poor of Oregon have very limited access to health care.  Sixty percent of Oregon doctors limit or do not see Medicaid (poor) patients.  More than 40% of Oregon physicians limit or do not see Medicare (pensioner) patients.[19]  [The Scribe, Medical Society of Metropolitan Portland, Nov. 19, 2004]
            With all of these problems resulting in reduction in health care to the vulnerably poor in Oregon, the Oregon Health Plan (Medicaid) continues to fund physician-assisted suicide for the poor.  You can understand why we are concerned that assisted suicide may become the "only choice" for some vulnerably ill patients.

Oregon's rate of assisted suicide is not lower than that of other states.
            There is no evidence that legalization of assisted suicide in Oregon has decreased the rate of physician-assisted suicide.  A medical article by Dr. William Toffler and me was recently published which shows that we do not know what the assisted suicide rate is in states other than Oregon.[20]  [Stevens & Toffler, J Clinical Ethics 2004;15:363-364]

Coercion is undetectable, as it is subtle and comes from a hopeless physician as much as from a hopeless family.
My wife's experience:
            I have personal experience regarding this matter.  My wife had been suffering for three years from advancing malignant lymphoma.  In May 1982, we met again with her physician to see what more could be done for her.  It was evident that not much more could be done other than the comfort care she was receiving.  As we were about to leave his office, her physician said, "Well, I could write a prescription for an 'extra large' amount of pain medication for you."  He did not say it was for her to hasten her death, but she and I both felt his intended message.  We declined the prescription, since her current pain medication was sufficient.  As I helped her to our car, she said, "He wants me to kill myself!"  She and I were devastated.  How could her physician, her trusted physician, subtly suggest to her that she take her own life?  We had felt much discouragement during the prior three years, but not the deep despair that we felt at that time when her physician subtly suggested that her suicide be considered.  Six days later she died naturally, with dignity and at ease in her bed, without the suggested medication.  
            This occurred twelve years before the legalization of assisted suicide in Oregon.  It exemplifies some doctor's feelings that "there is nothing more I can do for you, so you'd be better off dead."   Assisted suicide destroys trust between patient and doctor.

Legalization of assisted suicide and euthanasia distorts medical care and divides the medical community.
            Doctors helping patients kill themselves as part of therapy results in distorted clinical thinking and tends to result in fewer efforts by the doctor to find a solution to the patient's distress.  Legalization of assisted suicide has divided the medical community.  Doctors used to work together to relieve distress.  But now for some doctors, assisted suicide is the 'obvious early option', while other doctors continue to strive to relieve distress with therapeutic means.

The Oregon Medical Association is opposed to Oregon's assisted suicide law.
            In order to clarify the Oregon Medical Association's (OMA) policy position on assisted suicide and Oregon's assisted suicide law, the OMA House of Delegates at the Annual Meeting on May 1, 2005 adopted the following policy report:
            "In May 1994 the OMA stated that it neither supported nor opposes the concept of physician assisted suicide.  In May 1997 the OMA stated that it is opposed to Oregon's physician assisted suicide law (ORS Chapter 127.800-897)."  "The OMA's position on the issue of physician assisted suicide - that it neither opposes nor supports it - is as adopted in May 1994.  Its opposition to ORS Chapter 127.800-897 (Oregon's physician assisted suicide law) is as adopted in May 1997." [21] [OMA Annual Meeting Report, May 1, 2005]

Oregon doctors are even more opposed to euthanasia than to assisted suicide.
            The Chief Operating Officer of the Oregon Medical Association, Mr. Kronenberg, stated to the Select Committee, "in my personal experience, the majority of physicians whom I have counseled. who have chosen to talk to me about it, the majority of them chose not to.  I think that the majority of those chose to refer to someone else" (Q 1043).  Asked whether doctor's attitudes would have been different if the ODDA had included provision for voluntary euthanasia as well as assisted suicide, he believed that in that event the OMA's position "would be the same as it was in 1970, that we opposed it on ethical and moral grounds.   It is a very great leap.  I think that physicians would feel the same way, that there is an extraordinary difference. in providing someone with the means to end their life and actually ending it" (Q 1048).[22] [Assisted Dying for the Terminally Ill Bill: Report, Paragraph 160]

A separate non-medical service for assisted suicide & euthanasia would have serious problems.
            Some witnesses to the Select Committee suggested that if a society thinks that assisted suicide is the way to go, then keep the doctors and nurses out of it.  Let there be a separate service which is well regulated and not part of health care provision.  [23] [Assisted Dying for the Terminally Ill Bill: Report, paragraph 242]
            However, it is highly probable that there would still be some involvement by physicians in that situation; such as determining medical diagnosis, identifying "terminal" condition, psychiatric evaluation and other areas where physicians may be involved.  It would be analogous to the Nazi doctor's situation in the late 1930s and early 1940s, where doctors in one medical institution identified disabled children to be euthanized, and the "marked" children would be sent to another medical institution where doctors  performed the euthanasia.  Doctors in those circumstances felt no responsibility for what they had done, because of the "divided" actions, and the Nazi regime's assurance that the "state took full responsibility".[24] [Lifton, The Nazi Doctors, pages 51-76]
            Those circumstances dulled the conscience of those involved.  Similar division of roles, loss of accountability, and loss of conscience would occur with physicians and non-physicians if a non-medical service were established to perform assisted suicide and euthanasia.  This would have a negative effect on the ethics of medicine and society.
            If such a non-medical service were established for the purpose of assisted suicide and euthanasia, doctors would also have less incentive to properly care for the medical needs of their patients.

The UK has led the world by example with hospice.
Legalizing assisted suicide and euthanasia sends the wrong message.
            I hope you will learn from the problems with physician-assisted suicide in Oregon.  Assisted suicide is not needed, and it puts vulnerable seriously ill people at risk.  The United Kingdom has led the world by example with hospice and the development of first-class palliative medicine and care in both hospitals and in the community.  Legalizing assisted suicide and euthanasia gives the message to the world that your patients are better off dead than cared for.  The UK should continue to lead in research and education into how to improve end-of-life care and palliative-care programs, and not in promoting unnatural assisted suicide and euthanasia.
            Professor Kathleen Foley, a neurologist at the Memorial Sloane-Kettering Cancer Center in New York, told [the Select Committee] that "the WHO, in developing its initiatives in palliative care, has asked governments not to consider such legislation for physician-assisted suicide and euthanasia until the needs of their citizens had been met with pain and palliative care services.  Clearly Britain is a leader in advocacy for hospice and palliative care, yet the full penetration of services in your country is not available, as in mine, and especially is not available for those of our ageing population with non-cancer diagnoses." [25]  [Assisted Dying for the Terminally Ill Bill: Report, Paragraph 86]