Are we sliding down the slippery slope?

Debate shifts to possible link with euthanasia

Even with the results of the yearlong Oregon Health Division study apparently showing the Death with Dignity Act functioning as intended, many Oregon health providers and ethics experts across the nation remain concerned about the long-term effects of such legislation.

"I think the law passed for reasons that are very different than why people are choosing to use it," says Bonnie Driggers, RN, assistant hospital director in oncology at Oregon Health Sciences University.

"All of the news media in Oregon and Washington focused on pain at the end of life as the main issue. And if you look at data from the Netherlands and you look at the data that was published by the Oregon Health Division, the primary reason for choosing physician-assisted suicide is pain unrelated to physical discomfort. It is suffering related to dependency or a loss of control over your life. And in the Oregon population, it is very disturbing to see the number of people who do not have a support system, who are single and that sort of thing," explains Driggers.

Driggers says she does not speak publicly about how she voted on the bill but finds it disturbing. Data from the first year, in her opinion, show that people voted in favor of the law as a means to avoid severe pain at the end of life, yet that’s not the main reason people are choosing to die.

"I think the reason is that Oregon in the last five years has done such a fine job in addressing pain and end-of-life issues in general," she says. "Data obtained from the Netherlands shows the same thing, that pain is not at the top of the list, but people who haven’t looked at the data think it is, and they have rationalized it."

An ongoing shift in the clinical definition of futile care in combination with the legalization of assisted suicide also has the potential to margin alize the needs of the elderly, severely ill, and disabled, asserts Nelson Lund, JD, professor of law at George Mason University School of Law in Fairfax, VA.

The traditional doctrine of futile care is that it is unethical to provide treatment that will do no good, Lund explains. "For instance, if a patient came to you with insomnia and asked you to amputate his feet, you would not do so because it would have no effect. An everyday example is patients who go to their physicians with a viral infection and ask for an antibiotic."

However, in academic circles, there is a movement to reconceptualize futile care to include quality of life criteria when considering continuing life-saving treatment in critically ill patients, says Lund.

"Some people want to redefine futile care to say, Well, even though this treatment will prolong the patient’s life, we don’t think that life under these circumstances is worth living, we’ll call it futile care and end treatment," Lund explains.

That debate, however, is not solely academic, says Gregory Hamilton, MD, a practicing Portland psychiatrist and president of Physicians for Compassionate Care, a group that opposed the legalization of physician-assisted suicide. "We get more calls about that than we do about physician-assisted suicide. You have half the family wanting to continue treatment, and the person who has the legal power of attorney doesn’t want to."

Hamilton cites two separate cases in his own experience of patients who wanted to continue to receive artificial feeding and hydration, but their physician providers independently determined that to be futile care and wanted such treatment withheld.

In one case, the family was able to get a court order to have the feeding and hydration restored. In the other case, the patient died. These experiences drive his concern about the legalization of assisted suicide and the power that physicians already have over their patients’ decisions.

"What happens is once you devalue the lives of the seriously ill by stigmatizing them and depriving them of the same protection against discouragement and suicidal ideation that the rest of us have — we who are not burdened with the diagnosis of being terminally ill — they are treated like second-class citizens," he says. "When you treat the seriously ill or any class of people as if they are separate under the law and don’t have the same protections, you erode the right of everyone."

Comparing Oregon to the Netherlands

Lund acknowledges that there are several protections written into Oregon law specifically to outlaw euthanasia, but very similar protections written into measures allowing assisted suicide in the Netherlands have had little effect, he contends.

"In the Netherlands, they never formally repealed the statute against physician-assisted suicide, but they do have this policy of nonprosecution. They have said they won’t prosecute physicians who do the following things, these include specific reporting requirements, getting a second opinion, etc.," says Lund. "Many physicians there ignore these requirements, and they are tolerated."

In 1990 in the Netherlands, there were 5,859 reported cases of euthanasia with the patient’s consent — including 400 cases of reported physician-assisted suicide — and 5,941 cases of euthanasia without the patient’s consent, according to a report provided to The Hague in 1991.1

A separate government survey of physicians that same year, known as the Remmelink Report, reported 2,300 cases of voluntary euthanasia with 400 cases of physician-assisted suicide, and an additional 1,000 cases of involuntary euthanasia.2

References

1. Medische Beslissingen Roknd Het Levenseinde: Rapport van de Commissie Onderzoek Medische Praktijk inzake Euthanasie (Medical Decisions About the End of Life: Report of the Committee to Investigate the Medical Practice Concerning Euthanasia). The Hague, 1991.

2. Van der Maas PJ, et al. Euthanasia and other medical decisions regarding end of life. Lancet 1991; 338:669-674.

Recommended reading

• Assisted Suicide Funding Restriction Act of 1997, H.R. 1003, 105th Congress, 1st Session, 1997.

• Annas GJ. Death by prescription — the Oregon initiative. N Engl J Med 1994; 331:1,240-1,243.

• Bachman JG, Alcser KH, Doukas DJ, et al. Attitudes of Michigan physicians and the public toward legalizing physician-assisted suicide and voluntary euthanasia. N Engl J Med 1996; 334:303-309.

• Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-assisted suicide and euthanasia in Washington State — patient requests and physician responses. JAMA 1996; 275:919-925.

• Center for Health Statistics, Oregon Health Division. Oregon Vital Statistics County Data 1996. Portland: Oregon Department of Human Resources; 1997.

• Dean AG, Dean JA, Coulombier D, et al. Epi Info, Version 6: A Word Processing Database and Statistics Program for Public Health on IBM-Compatible Microcomputers. Atlanta: Centers for Disease Control and Prevention; 1995.

• Drickamer MA, Lee MA, Ganzini L. Practical issues in physician-assisted suicide. Ann Intern Med 1997; 126:146-151.

• Drug Operations Section, Drug Enforcement Agency. ARCOS 2 quarterly report. Report 4. Washington, DC: Department of Justice; 1998, pp. 43-44.

• Emanuel EJ, Daniels ER, Fairclough DL, Clarridge BR. The practice of euthanasia and physician-assisted suicide in the United States — adherence to proposed safeguards and effects on physicians. JAMA 1998; 280:507-513.

• Emanuel EJ, Fairclough DL, Daniels ER, Clarridge BR. Euthanasia and physician-assisted suicide: attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996; 347:1,805-1,810.

• Haley K, Tolle S. "Responding to Professional Non-compliance." In: Haley K, Lee M, eds. The Oregon Death with Dignity Act — A Guidebook for Healthcare Providers. Portland: Oregon Health Sciences University; 1998, pp. 40-41.

• Hedbert K. "Oregon Health Division Reporting." In: Haley K, Lee M, eds. The Oregon Death with Dignity Act — a Guidebook For Healthcare Providers. Portland: Oregon Health Sciences University; 1998, pp. 43-45.

• Lee MA, Nelson HD, Tilden VP, et al. Legalizing assisted suicide — views of physicians in Oregon. N Engl J Med 1996; 334:310-315.

• Long L. Basics on ballot measure 51. Salem: Oregon Legislative Policy and Research Office; Oct. 1997, pp. 1-6.

• Meier DE, Emmons C-A, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338:1,193-1,201.

• O’Keefe M. Dutch researcher warns of lingering deaths. The Oregonian, Dec. 4, 1994:A1.

• O’Keefe M. The pursuit of liberty and death. The Oregonian, Oct. 19, 1997:A1.

• Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5:649-655.

• Oregon Administrative Rules 333-009-0010.

• Oregon Death with Dignity Act, Oregon Revised Statute 127.8000-127.897.

• Pellegrino ED. "The False Promise of Beneficent Killing. In: Emanuel LL, ed. Regulating How We Die. Cambridge, MA: Harvard University Press; 1998, pp. 71-91.

• Preston TA, Mero R. Observations concerning terminally ill patients who choose suicide. J Pharm Care Pain Symptom Control 1996; 4:183-192.

• Slome LR, Mitchell TF, Charlebois E, et al. Physician-assisted suicide and patients with human immunodeficiency virus disease. N Engl J Med 1997; 336:417-421.

• Tolle SW. Care of the dying: clinical and financial lessons from the Oregon experience. Ann Intern Med 1998; 128:567-568.