Wednesday, March 7, 2018

Assisted suicide in Oregon: The reality.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Lozier institute has published a thorough analysis of the reality of assisted suicide in Oregon by Richard Doerflinger based on the Oregon Health Authorities 2017 assisted suicide report.
Doerflinger, who is an associate scholar with the Charlotte Lozier Institute and a Public Policy Fellow at the University of Notre Dame’s Center for Ethics and Culture, examines the report based on key themes.

He first examines the problem with uncovering abuse of the law.

Physicians, witnesses, and others involved in the process need not comply objectively with the law’s requirements, but only show “good faith” compliance, exempting physicians from their usual obligation not to be negligent. The prescribing physicians need not refer a patient for psychological evaluation even in a clear case of clinical depression — such referral is required only if the doctors think the patient’s depression causes “impaired judgment.” So if they agree with the patient’s judgment that he or she is better off dead, there is no referral. 
the Oregon system is tailor-made to conceal, not reveal, abuses. The physicians involved in prescribing the drugs are the only people allowed to file reports on these cases. The Oregon Health Authority itself says it has no legal warrant to do anything but take this self-reporting at face value. If other doctors found that the patient is not eligible for assisted suicide, patient or family can simply keep trying other doctors until they find one ardently committed enough to assisted suicide to sign the forms – and it is only that last doctor who files a report. So the very cases that most cry out for investigation – in which other doctors had concluded that this patient is not eligible to receive lethal drugs – are those in which the only report is most likely submitted by ideologically committed physicians inclined to ignore or conceal problems. Those physicians are then told by the state to falsify the death certificate, listing the underlying illness as cause of death, so there will be no autopsy or independent scrutiny. And after filing an annual report from which all identifying information has been removed, the state destroys the original reports.
As I have always stated, the Oregon assisted suicide law is designed to protect physicians who are willing to prescribe lethal drugs.

He then examines the data in the 2017 assisted suicide report:
In 2017, there were 218 lethal prescriptions written and 143 patients died from these drugs. The annual increase in deaths has accelerated in the last four years, with almost twice as many assisted suicides in 2017 (143) as in 2013 (73). 
Fourteen of the 2017 deaths were from drugs prescribed in previous years. So of the 218 prescriptions filled in 2017, as many as 89 lethal barbiturate overdoses (with instructions on how to use them to take a life) are in the population, and the state that authorized their distribution has no idea what became of them. In all, 1,967 lethal prescriptions have been written and at least 1,275 patients have died from these drugs, leaving a total of 692 lethal overdoses unaccounted for.
He then examines the issue of mental health and assisted suicide:
From 1998 to 2012, only 6% of patients on average were referred for evaluation; this went down to just under 4% in 2013-2016, then 3.5% in 2017. The state has not cited a single case out of 1,275 in which a patient was found ineligible for assisted suicide because an evaluation found depression or other mental condition impairing judgment. 
...The essential question, then, is this: What checks are there against depression or other mental condition, misuse of the drugs by others with their own agendas, subtle or overt coercion, etc., at the time of death? 
The answer is: There aren’t any.
He then examines the oversight of the Oregon assisted suicide act:
The only person who can report on the circumstances at that time is the prescribing physician, and that person was only present 16% of the time in 2017 (an average of 15% for all years). In past years, a health care provider other than the prescribing physician was present 27% of the time on average; in 2017 that is down to 13%. Thus in 2017 no health care provider was present 71% of the time. 
Since the prescribing doctor, who is required to self-report the act, is rarely present at the death, therefore there is little to no oversight of the law.
Doerflinger then examined the definition of “Incurable and irreversible” terminal illness in the Oregon law based on the recent research by a Swedish investigator who communicated with the Oregon Health Authority. Doerflinger states:
Fabian Stahle, a Swedish investigator who contacted a state health official in Oregon to clarify how the phrase “terminal disease” is interpreted by those who monitor the law’s implementation. He found that patients are eligible for assisted suicide if the two doctors think they are likely to die in six months without any treatment — even if they could have been cured by treatment, or could live for years or decades if treated. If the patient refuses potentially curative treatment (as a suicidally depressed patient, for example, may well do), or treatment is denied by someone else like the physician or a health insurance company, that patient becomes “terminal” and can receive lethal drugs. Essentially you are terminal if, by withholding treatment, you can be made terminal.
He then uncovers further issues with the terminal definition:
Overall, the time from first request for the drugs, to death from those drugs, has been as long as 1,009 days (over five times the projected life expectancy); in 2017 it was as long as 603 days. 
In 2017, some 77% of the patients had various forms of cancer. Others had chronic conditions with a less predictable trajectory toward death, such as cardiac and respiratory conditions found in many seniors, neurological conditions like ALS (Lou Gehrig’s disease), and even metabolic conditions like diabetes. In 2016 the list included “benign and uncertain” growths; overall, three patients have been found eligible for the lethal drugs although doctors listed no illness at all.
The next question that he examined was the issue of uncontrolled pain.
The reality is that pain, or even concern about future pain, ranks low on the reasons that patients cite for getting the lethal drugs. In 2017, only 21% cited this concern (compared to an average of 26% in past years). The most common reasons are being “less able to engage in activities making life enjoyable” (88%), “losing autonomy” (87%), and “loss of dignity” (67%), all of which could be cited by someone with a chronic illness or long-term disability that is not terminal. The most significant change is that in 2017, some 55% of patients (compared to an average of 42% in past years) say they are obtaining the lethal dose because they are a “burden on family, friends or caregivers” – a feeling easily communicated to patients by those other parties, and by the existence of a government policy singling them out for “assistance” in suicide.
Further to that he examined the problems with assisted suicide's
In 2017, at least two patients had seizures after ingesting the drugs. Overall, at least 25 patients (including one in 2017 and three in 2016) regurgitated some of the dose, and seven overall have regained consciousness and died later of natural causes. (Interestingly, there is no record of anyone choosing to go through this a second time.) For 638 patients, 101 of them in 2017, it is not known whether such complications occurred, presumably because the prescribing physician who filed the report was not present. The time period from ingesting the drugs to death is unknown in most cases; in the 40 cases where it is known in 2017, patients took as long as 21 hours to die, compared to nine hours in 2016, with an overall maximum of 101 hours (over four days). In 2017 it took as long as four hours for the patient to lose consciousness, compared to a maximum of one hour previously; this figure is not known for 105 of the 143 patients in 2017.
Finally he examined the issue of medical treatment options:
One significant change: In 2017, only 31% of the patients had private health insurance (compared to 54% in 2016), and 68% had only governmental insurance such as Medicaid and/or Medicare (compared to 45% the previous year). This is troubling in light of Oregon’s Medicaid rationing plan, which has been known to deny potentially life-prolonging treatment to patients while highlighting the availability of assisted suicide. 
Not that private health insurance is a guarantee against rationing. In 2017, Nevada physician Brian Callister revealed that he had sought approval from insurance companies in Oregon and California (the latter also having an Oregon-style law) for two patients he thought could be cured by a treatment available in those states – in both cases, he says, the companies refused coverage for the treatment but suggested that he consider assisted suicide.
Richard Doerflinger concluded his article by stating:
This is the updated reality of physician-assisted suicide in the state whose law is seen as a model for the nation. Chronically ill seniors, potentially victims of untreated depression and the impression that they have become a “burden” on others, are nudged to a premature death that may be more gruesome than they’ve been led to believe, with no one usually present at the time of death to check whether they are competent, badgered by others, or overtly coerced toward that death. This is what has become known as “death with dignity” in Oregon, and advocates are working to spread it to far more states.
Clearly, the theory of assisted suicide in Oregon and the reality are very different.


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gadfly said...

Cancer number one, closely followed by ALS and three people without illnesses at all. This accords with my own research done in two different contexts, with two different sample sizes: Cancer, MS/ALS, or ALS/MS as top three. (Adrian Rhodes, 2014-2018, unpublished manuscripts.) This tells me we need to improve psychosocial supports, community supports and pain management for people with those illnesses. And it's unethical to leave a patient in pain without treating the pain, as opposed to killing the patient to achieve that end.