1	Debating Assisted Suicide Christian Life Resources Clearly Caring 2003 Convention 10/18/2003 Kenneth R. Stevens, Jr., M.D. President Physicians for Compassionate Care Portland, Oregon
2	Kenneth R. Stevens, Jr., M.D. M.D. Degree U of Utah 1966 Residency Radiation Oncology Oregon Oregon Health & Science University Professor and Chair Radiation Oncology Department Physicians for Compassionate Care Founding Member – 1995
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4	PCC Education Foundation Members affirm an ethic based on the principle that all human life is inherently valuable, and that Physicians’ roles are to heal illness, alleviate suffering, and provide comfort for the sick and dying. We work to ensure appropriate care for our patients, to speak out for the inherent value of human life, and to uphold the time-honored values of our profession.
5	PCCEF encourages physicians to: Heal the patient. Enhance support for patients who cannot be healed. Avoid unnecessary therapies that will unduly prolong the dying process. Educate health professionals and the public about the dangers of physician-assisted suicide and euthanasia, realizing that they are fundamentally incompatible with our role as healer.
6	PCCEF encourages physicians to: Encourage state of the art care for dying patients, including optimal pain management and the recognition and treatment of depression. Update health professionals on current pain management technology and palliative care for clinical use to help confront the challenges of serious, chronic, and terminal illness with honesty, caring and commitment. Collaborate with other organizations to promote our mission.
7	For 2400 years, physicians have withstood the allure of promoting death. We have cared for the weak and outcast when others have turned away. Today’s pressures include economic ones; such forces may compromise patient care and promote assistance in suicide.
8	We reject assisted suicide and euthanasia and their inherent conflict of interest for the patients’ well being. Rather, we choose to be bearers of hope and sources of strength, and will attend to our patients’ needs until the natural end of life.
9	Understand the role of physicians and others in caring for the seriously ill Consistent ethical traditions: healing & comfort. Use all knowledge, skills and compassion in caring for and supporting the patient. Medicine and physicians are not to intentionally cause death. The patient-physician trusting relationship is the most important asset of physicians and is for the protection of patients.
10	Physicians have the duty to safeguard human life, especially life of the most vulnerable: the sick, elderly, disabled, poor, ethnic minorities, and those whom society may consider the most unproductive and burdensome
11	In the United States, it is a very serious major crime to assist another person in their suicide; unless you are a physician in Oregon and assisting a terminal patient to commit suicide.
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13	The proponents of Physician-assisted Suicide (PAS), Death with Dignity –(DWD) in the U.S. want to change that criminal-designation, They desire that Physician-assisted Suicide be legal in the entire United States. DWD efforts are very persistent in working to change our national/state laws for that purpose.
14	The DWD focus is to give doctors the legal right to kill patients Their focus is not on comfort care. Their focus is not on pain management. Their focus is not on palliative care. Their focus is to make PAS legal.
15	The legalization of PAS does not give any new rights to patients. It’s purpose is to legally protect doctors who write prescriptions for lethal drugs. Legalization of PAS takes away from terminally ill patients, the protection against doctors who order their death by a prescription for lethal drugs.
16	This is a battle and war for the safety & welfare of vulnerable and seriously ill people. We need to understand the battle field.
17	Definitions Physician-assisted Suicide: patient self-administers the lethal dose that has been prescribed by a physician. Euthanasia: active causation of death of patient by a physician, by lethal injection or other means. Voluntary Euthanasia: patient consents to and is aware of the euthanasia. Involuntary Euthanasia: patient is unaware of, and may be opposed to, the euthanasia.
18	Euphemisms for PAS “A euphemism is a substitution of a mild or indirect expression for one thought to be offensive or blunt.” Hastening death Death with Dignity DWD Comfort Death Aid in Dying Act of Self-determination
19	Understand the Strategies, Methods & Message of the DWD Movement
20	Strategies & Methods of Pro-PAS & Euthanasia Movement Use Euphemisms to mask & distort the truth, and cloud the issues. Neutralize the medical and other health professions regarding PAS and euthanasia.
21	Strategies & Methods of Pro-PAS and Euthanasia Movement Influence the public by fostering fear of dying, suffering, pain and medical technology. Influence the public by exploiting self-determination and limitless autonomy. Influence the public and professions by falsely saying that PAS is in the public good.
22	Fostering Fear of pain, suffering and disabilities I don’t want: Painful and protracted death/dying Disabilities To be on life-support To be in a nursing home To run out of money & resources Loss of control, self-image To be alone To be a burden to family & friends
23	Exploiting Self-Determination & Autonomy I want: Control of my life and death To keep my self-image To have the right to die I want to die when I am tired of living Religionists to stay out of my life and death “It is my body, I want to choose when & how I will die.”
24	Falsifying Public-Good The PAS law in Oregon has resulted in improved end-of-life care in the nation. There are safeguards in PAS laws There is only good and no danger from PAS There are economic benefits from PAS
25	How do those who value human life and compassionate care defend society against the PAS & euthanasia movement? Know and speak the truth with clarity. Do not fear. Join with & support organizations which support quality end-of-life care and oppose PAS.
26	What is physician-assisted suicide? A doctor writes a prescription for lethal drugs (barbiturates/sleeping pills) to be taken by a patient. In Oregon and The Netherlands morphine-like drugs are not used. A prescription is a written order or directive to the patient. PAS is really doctor-ordered, doctor-prescribed, or doctor-directed suicide.
27	When a doctor writes a prescription for PAS, the message is: Your life is not worth living You are better off dead I don’t value you or your life I want you dead I order you to die I direct you to die It destroys trust between patient and physician.
28	“You will never get accustomed to killing somebody.” Writing a lethal prescription is like “giving a patient a loaded gun and just asking them not to shoot before you leave the house.” Pieter Admiraal, M.D. leader of The Netherlands’ euthanasia movement American Medical News 9/15/1997
29	“Now, assisted suicide---that could be a growth area for us.”
30	“Even the most humane and conscientious physicians psychologically need protection against themselves and their weakness and arrogance, if they are to care fully for those who entrust themselves to them.” Leon Kass
31	“A physician-friend who worked for many years in a hospice, caring for dying patients explained it to me most convincingly:” Leon Kass
32	“Only because I knew that I could not and would not kill my patients was I able to enter most fully and intimately into caring for them as they lay dying.” Leon Kass, “I will give no deadly drug”: Why Doctors must not kill, in The Case Against Assisted Suicide, For the Right to End-of-Life Care, Ed. Foley & Hendin, Johns Hopkins Press, 2002, page 30
33	Dr. Peter Reagan who wrote of his experience in assisting his patient “Helen” with her suicide, said that his patient’s steadfast desire to cut short her days was disquieting. Having success defined as her ability to take her own life was strange. If he were dying, “I made a commitment that I wouldn’t ask my own doctor to help in this way, because it’s a lot to ask.” (Lancet 353:1265-67, 4/10/1999) (The Oregonian 11/14/2001)
34	Pro-life Compassionate Caring Arguments regarding Life-support technology There is a constitutional right to consent to and refuse medical treatment. You cannot be forced to be on life-support machine Stopping life-support is very different than physician-assisted suicide. Being on or off life-support has nothing to do with physician-assisted suicide.
35	Pro-Life Compassionate Caring Arguments regarding Pain We should focus on killing the pain and not the patient. We need to improve the care of patients, not kill them. Uncontrolled pain in the terminally ill rarely occurs. In Oregon only a very small minority of patients dying of Physician-assisted Suicide chose it because of fear of pain in the future. This was not because they were having pain. There is an inverse relationship between cancer patients experience with pain and their favoring PAS. The general public is more in favor of PAS than are those who have painful cancer.
36	The message that proponents of PAS are giving to the public and to patients, is that doctors can do a better job of killing patients than they can of caring for their medical needs. Patients worry that doctor would be judge, jury and executioner.
37	What about tragic cases of individual suffering Oliver Wendell Holmes: “Hard cases make bad law.” “Hard individual situations make bad public policy” Cohn & Lynn, Vulnerable people: Practical rejoinders to claims in favor of assisted suicide, in The Case Against Assisted Suicide, Johns Hopkins Press, 2002, page 260
38	If intolerable suffering were the reason for physician-assisted suicide, then why is PAS not successfully promoted in areas of the world where there really is such intolerable suffering? Why is PAS only successfully promoted in affluent societies?
39	The DWD Movement have acknowledged that physical pain and suffering are not the main argument for PAS. They propose other arguments.
40	People with disabilities fear PAS Disability Rights advocates are appalled at the negative PAS message regarding seriously ill people with disabilities. PAS advocates de-value those who are disabled by playing on the “horror of dependency”. The disabled fear they may be the next targets of PAS. DWD = Down with Dependency/Disability
41	Depression Depression is the leading cause of suicide. There is a direct relationship between depression and favoring Physician-assisted Suicide. Depression needs to be diagnosed and properly treated with counseling and medications. Depression is not a contraindication to PAS in Oregon, a person requesting it just has to “be capable”.
42	Pro-life Compassionate Caring Arguments regarding Money, Resources, Burden There are financial reasons why HMOs or state medicaid programs may promote cheaper PAS, rather than have prolonged cost of caring for a patient with chronic disease. There is concern that vulnerable people with limited-resources my feel that PAS is their only choice. An individual with an 11-yr history of chronic pain called an Oregon doctor in April, 2003,requesting PAS because of his frustration with recent cutbacks in his medical care in Oregon. Oregon is in a significant economic crisis. It leads the nation in unemployment and hunger.
43	Oregon’s Economic & Medical Crisis Oregon leads the nation in unemployment and hunger Wall Street Journal 8/2003: “Oregon’s economy is worst in the nation.” Because of rising costs, including liability costs, one half of Oregon physicians are not accepting Oregon Health Plan patients
44	It is dangerous to be poor and sick in Oregon in 2003 9/27/03
45	Half of Oregon doctors in 2003 will no longer take care of Oregon Health Plan (Medicaid) patients 9/25/03
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47	Because of significant budget deficits, the Oregon Health Plan in late 2002 and early 2003 stopped benefits for many Oregonians on the Oregon Health Plan (Medicaid). This resulted in many serious medical problems and even deaths.
48	Oregon Health Plan Cuts off Drug Benefits to many Oregonians 3/9/03
49	Oregon cuts financial aid for medication for poor, including those mentally ill. 3/7/03
50	“This notice is about an important change,” 2003
51	Feb. 23, 2002
52	“Lapses in Oregon’s mental health system have contributed to at least 94 deaths in 3 ½ years” 12/29/2003
53	Oregon cuts medication benefits for poor, including anti-seizure 3/9/03
54	Oregon cuts anti-rejection medication benefits for organ-transplant patients 3/30/2003
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56	Physician-assisted Suicide and Euthanasia can help solve the problem of rising health care costs says Derek Humphrey of Hemlock Society 12/2/1998
57	The Oregon Medicaid cost of 2 PAS deaths in 1998 was $99
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60	Physician-assisted Suicide in Oregon
61	The Oregon Department of Human Services Annual Report on DWD sanitizes the information released to the public. The Oregon DWD organization claims to have directed and controlled 80% of the PAS deaths in Oregon. They know and control the information released to the public. There is a mask of silence regarding the details of PAS in Oregon.
62	Legalizing PAS does not improve end-of-life care “Last Acts” in a 11/18/02 report gave Oregon mixed ratings on end-of-life care. In several aspects of palliative care, Oregon received lower grades than many states which ban assisted suicide. Passage of laws against assisted-suicide does not decrease the use of morphine.
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67	For many in our society, there is no right or wrong, there is only extreme autonomy. They believe: We succeed in this life based on our own achievements. We prosper according to our own intelligence. We conquer according to our own strength. Anything we choose to do is okay because there is no wrong.
68	The DWD movement exploits autonomy and self-determination as their main argument for PAS. The patients in Oregon requesting PAS have been described as being extreme in their desire for continuing their coping mechanism of control in dying as they have in their life.
69	“Oregon Physicians’ Perception of Patients who Request Assisted Suicide and Their Families” Ganzini, L., et al, Journal of Palliative Medicine 6:381-390 June, 2003
70	Physicians described requesting patients as: Strong and vivid personalities characterized by determination & inflexibility Wanting/demanding to control the timing and manner of death Wanting to avoid dependence on others Forceful, persistent Refusing medical interventions including palliative treatments
71	Physicians used the following words to describe the requesting patients: Independent Self-directed Lack of reliance on others Dreaded dependence Determined In-charge Strong-willed Stubborn Prideful Very opinionated Eccentric Crusty Solitary odd ducks Outspoken Forthright Adamant Uncompromising Very demanding
72	Thus, we have controlling, independent people arguing to establish a public-policy legalizing PAS. What is wrong with that? Once the public-policy has been established then the weak and vulnerable become subject to being killed by doctors.
73	The DWD Movement Exploits & Promotes Unbounded Unbridled Pridefulness Chief Deadly Sin Chief Worldly Virtue Chief Deadly Virtue
74	Once it is legal and doctors are given the power to kill people, the powerless and dependent will be swept up and disposed of in our society. Consider what has happened in The Netherlands, and it will occur in other nations as well.
75	The Netherlands - 1995 Study
76	In The Netherlands the Physician-caused Death Criteria has expanded from: Request from terminally person with intolerable suffering, to Request from psychologically distressed person, to No-request from patient required, to Euthanizing babies with birth defects. There are no Safeguards in The Netherlands.
77	The DWD movement speak of the “safeguards” in Oregon’s DWD Act. However, these “safeguards” are really boundaries or “fences”. They are a barrier for access to PAS for those outside these boundaries.
78	This is a very fatal flaw in the DWD argument. Autonomy & Boundaries don’t mix. Boundless autonomy is boundless. Unbounded autonomy has no boundaries. The boundaries around PAS will be elastic. They have stretched like a rubber band, and will continue to stretch. The nature of unbounded autonomy ultimately leads to loss of autonomy.
79	If it is autonomy that is wanted, then give to all people the right and access to use lethal drugs without physician involvement. The danger of this is obvious.
80	Kate Cheney-age 85 died 8/29/1999 “Kate’s choices may be influenced by her family’s wishes and her daughter may be somewhat coercive.” – evaluating psychologist
81	There is a mistaken opinion that all Oregon PAS patients have self-administered the lethal drugs. The Washington Post (11/3/99) told how Dr. Rasmussen opened 90 capsules and poured the powder into chocolate pudding. He gave the mixture to the woman’s son who spooned the mixture into his mother’s mouth. Another son gave her sips of water to wash the solution down. All she did was swallow. Is this self-administration?
82	Patrick Matheny 43–yr old. His brother-in-law had to “help” him with PAS because he could not have done it by himself.
83	The deputy Oregon state attorney general, David Schuman, suggested that the Oregon physician-assisted suicide law may discriminate against those who are paralyzed or on life support and they can’t swallow. (Oregonian 3/13/99) Eliminating this “discrimination” would require euthanasia.
84	Even in Oregon there is confusion, this was clearly a case of euthanasia (lethal injection) and not PAS. No criminal charges were filed !
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86	Physicians who care for patients should not order and direct their death It is against medical ethics: “Give no deadly drug”. It is too dangerous to give the power to kill patients to the medical profession. It destroys the inherent trust between patient and physician. It devalues the inherent value of human life. It desensitizes us towards any type of suicide.
87	My personal story: In 1982, my terminally ill wife and I went to her doctor. “Nothing more can be done.” “I can write an “extra-large” prescription.” “He wants me to kill myself.” She was devastated that her physician, her trusted physician, would subtly suggest that her life was no longer of value.
88	Recommended Publications The Case Against Assisted Suicide, Foley & Hendin, Johns Hopkins Press, 2002, $50. Forced Exit, Wesley Smith, Spence Publishing, 2003, $18. www,spencepublishing.com Culture of Death, Wesley Smith, Encounter Books, 2000, $24. Power Over Pain, How to get the pain control you need, Chevlen and Smith, International Task Force (paperback), 2002, $13. Protecting Psychiatric Patients and Others from the Assisted-Suicide Movement, Olevitch, Praeger Publishers, 2002. Tuesdays with Morrie, Albom, Broadway Books (paperback), 1997, $12.
89	Recommended Websites www.pccef.org Physicians for Compassionate Care www.iaetf.org International Anti-euthanasia Task Force www.acljliffe.org American Center for Law & Justice www.hospicepatients.org Hospice Patients Alliance www.ama-assn.org American Medical Association www.physiciansforlife.ca Canadian Physicians for Life www.euthanasiaprevention.on.ca Euthanasia Prevention-Canada www.notdeadyet.org Not Dead Yet
90	More Websites www.dyingwell.com Dying Well-Ira Byock www.nrlc.org National Right to Life Committee www.painlaw.org Pain Law www.chninternational.com Compassionate Health Care Network – Canada www.donoharm.org.uk Do Not Harm U.K. www.ohd.hr.state.or.us/chs/pas Oregon DWD