PCC PHYSICIANS FOR COMPASSIONATE CARE NEWS
Affirming An Ethic That All Human Life is Inherently Valuable
Vol.4, No.1, Spring 2001
William M. Petty, MD, President
Kenneth R. Stevens, MD, Vice President
Miles J. Edwards, MD, Secretary/Treasurer
William L. Toffler, MD, National Director
N. Gregory Hamilton, MD, Senior Scholar
Pamela J. Edwards, MD
John F. Schilke, MD
Thomas Pitre, MD
Mark Kummer, MD
Gerald B. Ahmann, MD, Medford
Thomas Comerford, MD, Bend
Robert DuPriest, MD, Eugene
Carl R. Jenson, MD, Coos Bay
Marvin M. John, MD, Hermiston
Steven L. Marvel, MD, Salem
George Middlekauf, MD, Roseburg
Palliative Care Consultant - Paul D. Stull, MD
OHD’s Reporting Mechanism Fundamentally Flawed
Leads to Faulty Data
Twenty-seven assisted suicides in the year 2000 brought the
state’s number of overdose deaths caused by Oregon doctors
to a tragic 70 cases. The most telling piece of information from
the Oregon Health Division’s (OHD) third annual report on assisted
suicide, however, was found in the comments section, “...our
numbers are based on a reporting system for terminally ill patients
who legally receive prescriptions for lethal medications, and do
not include patients and physicians who may act outside the law” (Hedberg,
et al 2001). If a doctor didn’t fill out the form, the case
wasn’t reported. There is no penalty for not reporting. A doctor
may simply choose not to do the paperwork, as is so common in Holland.
Hedberg also referred to last year’s report on the subject
of underreporting; it said, “Underreporting cannot be assessed
and noncompliance is difficult to assess.” We are left with
the impression that OHD’s figures are not the actual figures
of those who have died by assisted suicide in the Oregon.
Inherent in OHD’s guidelines on reporting are the potentials
underreporting and biased sampling. OHD’s own guidelines don’t
require it to report all cases. The standard OHD guideline states,
“After the death of a patient for whom a prescription for medication
to end life has been written pursuant to the Act, the Division may
send the attending physician a confidential form to verify information
concerning the circumstances surrounding the patient’s death” [(Reporting
333-009-0010 (b)]. So, they also may not inquire, for example, in
the case of a botched suicide when the patient does not die from
the overdose or there are other complications.
Furthermore, OHD indicates in this year’s report, “Vital
Records files are searched periodically for death certificates that
correspond to physician reports. The death certificates allow us
to confirm patient’s deaths and provide patient demographic
data.” However, the local assisted suicide advocacy group which
claimed 21 of the 27 assisted suicide cases in 2000 (US Newswire,
February 20, 2001), insisted in a Portland Community College class
( December, 1999) that the doctors not write ‘assisted suicide’ on
the death certificate of these patients, but instead indicate the
patient’s underlying disease on the death certificate. So,
how is OHD going to identify and match the cases? Yet even those
cases which were mentioned by OHD in this year’s report were
disturbing. Doctor’s listed fear of being a “burden on
family, friends or caregivers,” in a startling 63% of the patients
who committed assisted suicide. Apparently, the “duty to die” is
becoming a reality in Oregon. And, despite the vast literature that
shows a high incidence of depression in the seriously ill, only 19%
of assisted suicide victims received even cursory referrals for psychiatric
For the third year in a row, concerns about pain trailed the list
of reasons for seeking assisted suicide, to the point of being negligible.
The threat of a patient’s intractable pain was frequently used
by activists to promote legalization of assisted suicide to the citizens
of Oregon. What has been considered the most compelling argument
among pro-assisted suicide strategists has been rendered myth by
the assisted-suicide doctors themselves. Yet, even here, serious
doubts remain, because OHD obtained no outside information about
the quality of pain treatment and palliative care provided by assisted-suicide
doctors. With such faulty reporting procedures, no wonder the conclusions
are flawed. Oregon citizens are left with no safeguards at all.
The AMA News responded to this year’s OHD report by saying, “...the
issues expressed by patients in Oregon can be addressed
without physician-assisted suicide...In the realm of setting public
policy, what we witness from this data raises serious doubts about
the urgency of legalizing and performing physician-assisted suicide.”
Assisted-Suicide -- a Response to Depression and Suicidal
According to information reported by the “...Dying Federation”
of Oregon, an advocacy group which promotes legalized assisted
suicide, “...only 4 of 12...” individuals who presented
to them with
so-called “violent” suicidal ideation completed their
suicides in 2000 by using an overdose of drugs provided by an Oregon
doctor. If 1/3 of the suicidal patients in any medical practice ended
up killing themselves with a drug overdose, something would be seriously
wrong. No physician would praise himself for those numbers. And what
about other depressed patients who were given assisted suicide? What
about people with a history of depression? What about those people
with a history of a previous “non-violent” suicide
attempt, by an overdose of drugs, who then ended their lives by completing
an assisted suicide with the help of the Dying Federation?
Joan Lucas was a 65-year-old Oregon woman with amyotrophic lateral
sclerosis, who made a suicide attempt using pills she had hoarded.
Instead of taking her to the emergency room for diagnosis and treatment,
her adult children watched her "...lay on her bed, moaning and writhing,
obviously in pain..." for an entire day, because they couldn’t
make up their minds what to do, according to the Medford Mail Tribune
(June 25, 2000), until "...it became real apparent she wasn't dying.
She was in agony." When Mrs. Lucas awakened, did the family get her
the evaluation and treatment she needed for her suicidal despair?
Far from it. They called George Eighmey, executive director of the
Oregon chapter of the Dying Federation. And Eighmey arranged her
The suicide doctor wouldn’t reveal his name, but he told a
local newspaper he decided to get a psychiatric opinion (not required
by Oregon) to "...cover my ass." Not to treat or even to protect
the vulnerable patient, but to protect himself!
The anonymous Oregon doctor’s major apparent concern was making
sure the suicide was carried out to specifications and protecting
himself. When no reputable psychiatrist could be found to perform
a perfunctory assisted-suicide evaluation instead of an evaluation
for treatment, a psychologist cooperated. This individual sent Joan
Lucas a Minnesota Multiphasic Personality Inventory (MMPI), a paper
and pencil questionnaire, because she could not travel to the clinic.
There is no indication the psychologist ever personally examined
the patient. Instead, the adult children read her the questionnaire
and filled out the form for her, apparently with some levity. "We
were just cracking up," they said. With such unreliable information,
the psychologist declared Joan Lucas was not depressed (Mail Tribune,
June 26, 2000). The psychologist made this determination despite
the fact that studies published in the American Journal of Psychiatry
show 94% of Oregon psychiatrists don't feel confident they can determine
when depression is affecting decisions about assisted suicide in
a single visit, no less, no visit at all.
There were no safeguards for Joan Lucas after her suicide attempt,
anymore than there were for Oregon’s first reported case, a
woman given assisted suicide drugs despite having been diagnosed
as depressed by her own doctor. People with depression and suicidal
ideation are committing assisted suicide in Oregon. This is a tragic
failure to provide appropriate treatment and prevention for the suicidal
FAILED ASSISTED-SUICIDE EXPERIMENT
N. Gregory Hamilton, M.D.
The Oregon Health Division (OHD) reported 27 assisted suicides in
2000, the same as in 1999. Again, the report gathered information
only from those needing to justify recent collusion in a suicide
-- the assisted-suicide doctors themselves.
The report claimed an assisted suicide rate of 9/10,000 Oregon deaths.
So, most people died without taking an overdose, while psychological
fears and social concerns led the rest to assisted suicide. The psychosocial
fears of all patients should be treated. And the victims of assisted
suicide should have been cared for, like all other dying individuals.
But they were not.
In fact, only 19% of the Oregon assisted-suicide victims reported
were even referred for a psychiatric opinion. We know at least one
of those referrals this year, as reported in the Medford Mail Tribune
(6/25&26/00), was made only to "cover" the suicide doctor.
After extensive doctor shopping, a psychologist sent home a Minnesota
Multiphasic Personality Inventory (MMPI) -- a multiple choice questionnaire
-- which the family helped the patient fill out, reportedly while
they were "cracking up" laughing. There is no evidence the psychologist
ever saw the woman in person or attempted to treat her psychological
fears and concerns.
This year, as in previous years, the OHD reported no failures or
complications. Sherwin Nuland from Yale medical school said he found
the Dutch data showing a complication rate of at least 15% more "credible" than
the rosy picture coming out of Oregon. The rate of unacceptable complications
reported by the Dutch ranges between 15 and 25%.
This year, too, the report was overly reassuring about lack of
financial pressures, but provided no information about known caps
and rationing of health care while assisted suicide is fully funded
by many Oregon HMO’s.
The experiment in death by assisted suicide has failed. What little
information one can glean from this biased data gathering points
to one conclusion: It's time to start improving treatment of the
psychological and social needs of seriously ill patients. It's time
to stop giving this small, but significant minority lethal overdoses
instead of the care they need and deserve.
Non-Participation in Doctor-Assisted Suicide
These recommendations are intended to protect your patients, preserve
your own moral integrity, and maintain your right not to participate
in assisted suicides.
Post a copy of your professional ethics so that patients
are informed in advance of your principles. *
Refrain from suggesting assisted suicide by naming it as a treatment
option, since assisted suicide is not a treatment. Initiating the
discussion of assisted suicide may suggest suicide and may also imply
the doctor’s approval of patient suicides.
Continue to treat all suicidal ideation as a symptom requiring diagnosis
and treatment. Just as with any other patient who brings up suicide,
if the seriously ill patient expresses suicidal thoughts, this symptom
should be taken seriously, even if the suicidal plan involves thoughts
of an assisted suicide. Suicidal
thoughts should be explored thoroughly. (A mental health history,
history of suicidal ideation and /or suicide attempts and family
history of suicides should be taken. Always use a mental status examination
to assess the patient for possible suicidal ideation. A
treatment plan for dealing with the suicidal patient is always necessary.
The psychological as well as the physical distress must both be addressed.
Medication evaluation, case consultation, family meetings, psychiatry
referral, referral for counseling, pastoral care, pain management
consults, and palliative care
evaluation may all be appropriate treatment interventions for the
suicidal, seriously ill patient.)
Let the seriously ill suicidal patient know you value his or her
life. As with other suicidal patients it may be appropriate to say
such things as: “I don’t want you to kill yourself. And
I assure you that your treatment team and I will care for you in
such a way that you won’t have to take your life through suicide,” or “I
you to kill yourself. If you get to feeling suicidal again, you call
me and we’ll take care of your pain or fear or whatever, so
you don’t feel like you have to take your own life.”
If the patient insists that his/her suicidal ideation is a political “right” rather
than a clinical problem, remind the patient that you value all human
life including theirs, that you wouldn’t condone any type of
suicide and that you want to continue to work with them with that
understanding in mind.
Reassure the patient. Recent health division reports show fear of
the future, not pain, leads to assisted suicide. Tell them they will
be able to handle their illness and the changes that come with it.
Address their fears of disabling symptoms. Dispel any bias they
might have against people with decreased functioning or people who
need help. Impart confidence by telling them that you and the treatment
team will be able to manage their pain, discomfort, or anxiety, if
they ever become a problem.
Continue to offer good care. The patient is free to transfer to
another doctor at their own initiative without your suggesting such
Decline to refer for assisted suicide. Remember that the law does
not require the physician to refer the patient to a doctor who will
participate in the suicide. Such a requirement would violate your
right to non-participation, since referral to facilitate assisted
suicide would constitute a form of material participation in assisted
suicide. Referral for suicide may contribute to the patient's discouragement
and may lead them to suicide. It would compromise the physician's
moral integrity. The law states specifically, “No health care
provider shall be under any duty, whether by contract, by state or
by any other legal requirement to participate...”(127.885 4.01.Immunities.
* The PCC ethics statement is printed inside this issue. A copy
of the professionally printed ethics statement is available from
PCC (a donation for costs and mailing is appreciated.)
P.O. Box 6042
Portland, Oregon 97228
PCC News Editor: Catherine Hamilton