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Death With Dignity
By Barry Yeoman, March-April 2003
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The law that would allow Colleen Rice to hasten her death will face a serious challenge this year in a federal appeals court. The Oregon Death With Dignity Act, which allows physicians to write lethal prescriptions for certain terminally ill patients, was used by only 91 Oregonians in its first four years on the books. Yet it has prompted a crusade by U.S. Attorney General John Ashcroft, who in November 2001 directed the Drug Enforcement Administration to prohibit doctors who prescribe fatal doses of medicine from writing prescriptions under the Controlled Substances Act. Ashcroft, a longtime opponent of physician-assisted suicide, claims the law violates the Act, which bars doctors from prescribing drugs for anything other than legitimate medical purposes. Though a federal judge blocked Ashcroft from enforcing his order, the issue will not be settled until all courts have weighed in. It seems inevitable that the case will go to the U.S. Supreme Court.
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| THE DOUBT On the final night, Colleen's daughter, Cathy Paul (above), told her mother: "You don't have to do this." |
The Oregon measure, unique in the nation, was approved twice by voters, despite heavy opposition from the Catholic Church. During those campaigns, critics charged that the law would trigger a "slippery slope"—from voluntary suicide to the Nazi-like extermination of undesirables.
In reality, the Death With Dignity Act is quite specific: It allows state residents with less than six months to live to request medication to end their lives "in a humane and dignified manner." The patient must ask three times over a period of 15 days or more, twice orally and once in writing. Two physicians must approve the petition, and they must refer the patient to counseling if there are signs of depression or other mental disorders. Finally, the patient has to be able to swallow the drugs without assistance. The physician is not allowed to intervene at the bedside.
In the five years since the law took effect, state officials say it has proceeded without medical complications. Those who have committed assisted suicide typically have been well-educated men and women with both health insurance and access to hospice care. "The critics have been terribly disappointed that the warnings they gave—that this would lead to euthanasia and selective killing of the elderly—have not come true," says Alan Bates, a physician and state legislator from Ashland. Instead, he says, the law has restored a sense of control to dying Oregonians, even those who don't end up taking the drugs. "The choice gives them a sense of peace," he says. "They know that at the end they won't be in terrible pain."
Even when they don't choose assisted suicide, Oregon patients feel more empowered to orchestrate the final months of their lives than patients anywhere else in the nation. The Beaver State leads the U.S. in many of the indicators for top-quality end-of-life care. Oregon consistently shows the lowest rates of in-hospital deaths, and the state ranks first in the use of medical morphine, a key indicator of whether terminally ill patients are receiving adequate pain control. Oregon is also among the top states when it comes to the availability of hospice services.
Yet physician-assisted suicide remains the most controversial aspect of end-of-life care, both in the state and the country—similar measures have failed by close margins in Maine and Hawaii—and some Oregonians are publicly rooting for Ashcroft to prevail. Critics point to data showing that loss of independence, rather than physical pain, is why 94 percent of patients opt for suicide.
"Dying makes us dependent on people, and we don't like that. We have to learn that it's okay to be cared for," says Father John Tuohey, an ethicist in Portland's Providence Health System who opposes the law. "Is this a good public policy to send out to people: When you become too burdensome, feel free to check out?"
Few people actually choose assisted suicide. In Oregon, 1 percent ask their doctors for prescriptions, and only .1 percent receive approval or follow through, says Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health & Science University (OHSU). The ones who do hasten their deaths follow a pattern: They are generally self-reliant, accomplished individuals who personify Oregon's pioneer spirit. "This is a group of people whose life experiences make them value control," says Linda Ganzini, an OHSU psychiatry professor who has studied the issue. "They often associate being cared for by somebody as humiliating. They develop this fierce individualism. In Oregon, they're admired for those characteristics." For people like this, the prospect of spending their last days in a morphine haze, soiling their bedsheets and being turned over by nurses, is worse than death itself. "It's not that their pain can't be controlled," says Katrina Hedberg, a medical epidemiologist for the Oregon Department of Human Services. "It's that to control it they give up what makes their life meaningful."
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