Yesterday, a doctor asked me about "do or refer" provisions in some of the newer bills seeking to legalize assisted suicide in the United States. For this reason, I now address the subject in the context of a 2018 Wisconsin bill, which did not pass.
The bill, AB 216, required the patient's attending physician to "fulfill the request for medication or refer," i.e. to write a lethal prescription for the purpose of killing the patient, or to make an effective referral to another physician, who would do it.
The bill also said that the attending physician's failure to comply would be "unprofessional conduct" such that the physician would be subject to discipline. The bill states:
[F]ailure of an attending physician to fulfill a request for medication [the lethal dose] constitutes unprofessional conduct if the attending physician refuses or fails to make a good faith attempt to transfer the requester's care and treatment to another physician who will act as attending physician under this chapter and fulfill the request for medication. (Emphasis added).[1]
The significance of do or refer is that it's anti-patient, by not allowing doctors to use their best judgment in individual cases.
Jeanette Hall with her son.
Consider Oregonian Jeanette Hall. In 2000, she made a settled decision to use Oregon's assisted suicide law in lieu of being treated for cancer. Her doctor, Kenneth Stevens, who opposed assisted suicide, thought that her chances with treatment were good. Over several weeks, he stalled her request for assisted suicide and finally convinced her to be treated for cancer.
Yes, Dr Stevens was against assisted suicide generally, but he also thought that Jeanette was a good candidate for treatment and indeed she was. She has been cancer free for 19 years. In a recent article, Jeanette states:
I wanted to do our law and I wanted Dr. Stevens to help me. Instead, he encouraged me to not give up and ultimately I decided to fight the cancer. I had both chemotherapy and radiation. I am so happy to be alive!
If "do or refer," as proposed in the Wisconsin bill, had been in effect in Oregon, Dr. Stevens would have been risking a finding of unprofessional conduct, and therefore his license, to help Jeanette understand what her true options were.
Is this what we want for our doctors, to have them be afraid of giving us their best judgment, for fear of sanction or having their licenses restricted or even revoked?
With proposed mandatory "do or refer," assisted suicide proponents show us their true nature. They don't want to enhance our choices, they want to limit our access to information to railroad us to death. ______
[1] AB 216 states:
156.21 Duties and immunities. (1) No health care facility or health care provider may be charged with a crime, held civilly liable, or charged with unprofessional conduct for any of the following:
(a) Failing to fulfill a request for medication, except that failure of an attending physician to fulfill a request for medication constitutes unprofessional conduct if the attending physician refuses or fails to make a good faith attempt to transfer the requester's care and treatment to another physician who will act as attending physician under this chapter and fulfill the request for medication. (Emphasis added).
* Margaret Dore is an attorney in Washington State where assisted suicide is legal. She is also president of Choice is an Illusion, a nonprofit corporation opposed to assisted suicide and euthanasia worldwide.
As the Executive Director of the Euthanasia Prevention Coalition, I am well aware that you are receiving information supporting and opposing the assisted suicide bill. As an elected representative your role is crucial, especially when considering issues such as assisted death.
Before voting on the legislation I ask you to watch the these film clips that are part of the Fatal Flaws film that was released last year. This film features personal stories and interviews with doctors, legislators, and individuals who have direct life experience with assisted death.
Dr. Kenneth R. Stevens is a Radiation Oncologist in Oregon who had a patient, Jeannette Hall, who asked for assisted suicide. Dr Stevens helped her find a reason to live and 19 years later she is grateful to be alive (Link to the story). Nancy
Elliott is a former three term New Hampshire State Representative who began to actively oppose assisted suicide based on her personal experience
when her husband was sick (Link to the story).
You may support assisted suicide in theory. In reality assisted suicide laws give doctors the right to be involed with causing the death of their patients when the patient is at the lowest time of their life.
Vote NO to assisted suicide.
Alex Schadenberg Executive Director – Euthanasia Prevention Coalition info@epcc.ca or 1-877-439-3348
I write to you from Sweden regarding HB 399 and SB 311 because these bills are similar to the Oregon law that is proposed here in Sweden. After contact with Oregon Health Authority I found disturbing information that was not available before and is highly relevant for HB 399 and SB 311 (below referred to as the ”Bills”). In this letter I would like to draw your attention to a dangerous passage in the Bills regarding the eligibility criteria that the patient shall be diagnosed with a ”terminal illness” that will result in death within 6 months. Regarding how this 6 months criteria must be interpreted, I have crucial information revealed from a correspondence I had with the Oregon Health Authority (OHA) in the end of 2017. I believe this information is very significant as the Bills definition of "terminal illness" is almost identical with the Oregon definition. In my correspondence the OHA acknowledged – for the first time officially - that they always had interpreted the 6 months criteria as ”without administration of life-sustaining treatment”, A3 and A8 in the correspondence (Link to the correspondence). See also my comments (Link to the comments). This interpretation is counter-intuitive because most people would take for granted that the meaning of ”terminal illness” is a disease for which there is no treatment or medication, i.e. that all hope is gone. But the interpretation is logically inevitable also for the Bills - and the implications are far reaching. As a patient has the right to refuse to receive treatment, any patient having a disease that potentially may develop into a terminal condition can make themselves eligible for assisted death – 'for any reason whatsoever'. Hence a trap-door for suicidal patients is imbedded in the Bills. This is unavoidable because the patient's autonomy ensures that it must be the patient himself who has to decide when enough is enough. For those who believe in the basic idea of these Bills, it is obviously unreasonable to request that, for example, a cancer patient who is exhausted by radiation and several unsuccessful chemotherapy treatments should be forced to undergo additional painful treatments with dubious results to gain access to assisted death. But where should we draw the line? Isn’t it also obviously unreasonable that a patient who has very good prospects to be cured can get assisted death by refusing treatment? Shouldn’t we require that a cancer patient accept at least one treatment before talking about assisted death – or at least to account for reasonable motives for their wish to die? Or what about a young diabetic who, in the despair of a broken relationship, wants to die and stops insulin so as to be able to obtain legal suicide assistance - shouldn't we regard that as unacceptable and ask for some sort of limitation? However, all such attempts to conditions intrude on patient autonomy – the very autonomy the Bills are intended to expand, not decrease – and leads to insoluble demarcation problems. The Oregon Health Authority has also come to this conclusion. (Link to the conclusion). (A4 and A5). So in the face of these two contradictory positions the Bills must surrender to the patient's autonomy - just as all other laws like the one in Oregon already have. As a result the obvious interpretation of the central concepts of “terminal” does not apply – but is left open to the patient's own decision, and hence the door is also opened to pure absurdities as to which people can be legally killed:
A cancer patient who has very good prospects to be cured, but denies treatment. An important reason is that she does not want to lose her hair. We are now in Oregon a while after their law for physician-assisted suicide came into force and the patient in question is Jeanette Hall. Her physician, Dr. Stevens is opposed to the law but was forced to acknowledge that his patient would be eligible to get the death pills she wanted because her cancer was likely to lead to death within 6 months if she was not treated. He managed however to convince her to take treatment and many years later Ms. Hall said: "It is great to be alive."
But nor all doctors are like Dr. Stevens. Dr. Charles Blanke, an oncologist with Oregon Health and Science University, told The Bulletin about one of his cases, a young patient with Hodgkin lymphoma with a more than 90 percent chance of survival with treatment. She did not believe in chemotherapy and feared its toxicity, despite Blanke’s efforts to convince her otherwise. After cleared by a psychiatrist Blanke approved her for assisted death, holding firm to his belief that doctors should not force patients to receive treatment. But afterwards Blanke asked himself:
“Why doesn’t that patient want to take relatively non-toxic treatment and live for another seven decades?”
The answer to Dr. Blanke’s question is just as simple as disturbing in the context of medical killing:
It is because a law that encourages sick people to commit suicide - by the obvious reason that for a suicidal person a socially accepted and smooth death administered by society is much more attractive than dying on one's own in loneliness, just as the young suicidal Belgian woman testifies in this video (Link to the video).
For any reason whatsoever. A person could, as Dr. Blanke’s cases, fear the possibility of side effects or future disabilities. But it could also be a parallel life crisis that is indirectly linked to the disease. And what about those patients who cannot pay for a potentially effective treatment? These Bills allow and encourage people that are not necessarily dying to commit suicide. These Bills allows and encourages people that are not necessarily dying to commit suicide. Please reject these dangerous Bills! Sincerely Fabian Stahle, Sweden
An open letter from Dr Kenneth Stevens, President, Physicians for Compassionate Care
Dr Ken Stevens
Since 1994, the proponents of Oregon's assisted suicide law have touted the importance of the safeguards and protections of that law. Now, Oregon's legislators are considering bills (HB 2232, HB 2903, SB 579) to eliminate many of those safeguards (eliminates waiting periods, expands definition of "terminal illness," permits lethal injection and inhalation euthanasia) and expand access to assisted suicide. Why and Why now? What is happening in medicine in the United States? There is increasing concern regarding the cost of medical care. A current (February 13, 2019) editorial in the Journal of the American Medical Association (JAMA), titled "Rationing of Health Care in the United States - An Inevitable Consequence of Increasing Health Care Costs" reviews the challenges of increasing medical costs, and it deems it critical to control health care costs. One way to control health care costs is to expand Oregon's assisted suicide law, to make it available to more people. The assisted suicide drugs can be less expensive than continued medical care. Derek Humphry, the founder of the Hemlock Society, argued in 1998 that physician-assisted suicide and euthanasia can solve the problem of rising health care costs, "Economics makes case for euthanasia", The Oregonian, Dec 2, 1998. We have seen this in Oregon, where the Oregon Health Plan refused to cover beneficial life-extending cancer treatment to patients such as Barbara Wagner, but offered assisted suicide instead. It is wrong and dangerous to expand the criteria for assisted suicide in Oregon. It is harmful to very vulnerable Oregonians. The Oregon legislature should not proceed with the proposed bills. I encourage you to contact your legislators regarding these dangers. Kenneth R. Stevens Jr., MD, President, Physicians for Compassionate Care Educational Foundation Further information:
By Dr Kenneth Stevens President, Physicians for Compassionate Care
Dr Bill Toffler, Dr Chuck Bentz, Alex Schadenberg, Dr Ken Stevens
The “Fatal Flaws – Legalizing Assisted Death” film was shown to over 200 people in Portland, Salem and Medford Oregon on February 17 - 19, 2019. This important film produced by Kevin Dunn of DunnMedia & Entertainment and Alex Schadenberg of the Euthanasia Prevention Coalition shows both sides of the assisted suicide and euthanasia experience in Europe and North America. The version shown was the 56 minute International educational version. Link to order the film.
Alex Schadenberg, the Executive Director of the Euthanasia Prevention Coalition from Ontario, Canada was present at all three presentations to introduce and provide additional information about this important film.
Drs. Bill Toffler, Chuck Bentz and Ken Stevens were also present to answer questions and provide additional commentary regarding assisted suicide.
Oregon Right to Life helped by organizing, advertising and obtaining venues for each of the presentations.
Each presentation was received with much interest and enthusiasm, with many appropriate questions and comments from attendees.
We appreciate all the effort that went into the production of this important film production; and to Alex Schadenberg in coming to Oregon from Ontario, Canada for these presentations.
We encourage those interested in assisted suicide and euthanasia information and experience, to purchase the Fatal Flaws film and accompanying printed pamphlets, and to show the film to others in your communities. You may be able to book Alex Schadenberg for your event. See www.FatalFlawsFilm.com for more information.
Alex Schadenberg Executive Director - Euthanasia Prevention Coalition
Dr Ken Stevens
Dr Kenneth Stevens is a physician in Oregon who helped his patient find a reason to live. The patient that I specifically recall is a patient by the name of Jeanette Hall. She was referred to me by her surgeon. She had a low rectal cancer.
So when I saw her I told her what she had, I told her we could treat it with radiation and chemotherapy and said that this is potentially treatable. She said I don't want to go through all that. I had an Aunt who lost her hair and I don't want to lose my hair.
She went back and saw the surgeon. The surgeon told her that if she wasn't treated that she would be dead within 6 months or a year.
The Oregon law says that if life expectancy is 6 months you qualify for the law so I could have written her a prescription for the lethal medication at that time.
She came back and I talked with her again and she said: why aren't you giving me the pills? I want the pills.
I learned more about her. I learned that she had a son who was going to the police academy. I said:
Wouldn't you like to see him graduate? That really made her think that I really have something to live for.
Jeanette Hall with her son.
She really struggled in her mind as to whether she was going to be treated or not treated. She finally accepted the treatment, it took a few weeks to give, it was not easy, she actually did lose her hair and her hair grew back and she was able to attend her son's graduation from the police academy.
Five years later, my wife and I were at a restaurant and she was there with a friend and she came over and she said:
Doctor Stevens, you saved my life. If I had gone to a doctor that believed in assisted suicide I would not be here. I'd be dead.
The film clip is from the Fatal Flaws film. The Fatal Flaws film can be purchased or rented at: (Link).
This article written by Ronald W. Pies, MD and Annette Hanson, MD and it was published by mdmag.com on July 7, 2018
Dr Annette Hanson
Introduction
In an age of “alternative facts”, it’s hard to sort out myth from reality when it comes to so-called ‘medical-aid-in-dying’ (MAID)—also called physician assisted suicide (PAS). By whatever label we attach to it, this practice involves a physician’s prescribing a lethal drug for a patient with a putatively terminal illness who is requesting this “service.” Some form of MAID/PAS is now legal in 5 states and the District of Columbia.
People of good conscience, including many physicians, are sharply divided on the ethics of MAID/PAS. Unfortunately, much of the support for this practice is founded on several myths and misconceptions regarding existing MAID laws and practices. Here are 12 of the most common.
1. Everyone has a “right to die”, including a right to take one’s own life, acting alone or with assistance.
Dr Ronald W. Pies
In contrast to “liberties”, rights entail the cooperation or assistance of others.1 Mentally competent people may be at liberty to end their own lives (i.e., will not be prosecuted), but there is no recognized right to suicide that involves the cooperation of others. In Washington v. Glucksberg [521 U.S. 702 (1997)], the US Supreme Court (USSC) denied that there is a constitutionally-protected “right to commit suicide” or a right to PAS. To rule otherwise, the majority held, would force them to “reverse centuries of legal doctrine and practice, and strike down the considered policy choice of almost every state.”
That said, the USSC has held that all competent persons have the right to refuse unwanted or “heroic” measures that merely prolong the dying process.2 Similarly, in Vacco v. Quill [521 U.S. 793(1997)], the USSC held that there is a legal difference between withdrawal of care and provision of a lethal intervention; i.e., everyone has a right to refuse medical care, but no one has a “right” to receive a lethal means of ending one’s life.
2. People who request “medical aid in dying” usually do so because they are experiencing severe, intractable pain and suffering.
Most requests for medical-aid-in-dying are not made by patients experiencing “untreatable pain or suffering”, as data from Oregon have shown; rather, the most common reasons for requesting medical aid in dying were loss of autonomy (97.2%), inability to engage in enjoyable activities (88.9%), and loss of dignity (75.0%).3
Many patients who request assisted suicide are clinically depressed and could be successfully treated, once properly diagnosed.
3. In states such as Oregon and Washington, where PAS is legal, there are adequate safeguards in place to ensure proper application of the PAS law.
In Oregon, reporting to the state is done solely by the physician prescribing the lethal drugs, who has a vested interest in minimizing problems. Moreover, if a physician was negligent in making the initial diagnosis or prognosis, there is no way to track this, since, by law, all death certificates will state that the person died of the putative underlying disease. At the same time, the physician is rarely present at the time the patient ingests the lethal drug, so the possibility of abuse—e.g., by coercive family members—cannot be adequately assessed.
The Oregon department of human services has said it has no authority to investigate individual death-with-dignity cases,4 and Oregon has acknowledged that its law does not adequately protect all people with mental illness from receiving lethal prescriptions.5 Thus, it is nearly impossible to determine cases in which, for example, terminally ill patients were pressured to end their lives by family members. A study in the Michigan Law Review (2008) found that “seemingly reasonable safeguards for the care and protection of terminally ill patients written into the Oregon law are being circumvented…[and that]…the Oregon Public Health Division (OPHD), which is charged with monitoring the law…does not collect the information it would need to effectively monitor the law…OPHD…acts as the defender of the law rather than as the protector of the welfare of terminally ill patients.”6
Kenneth R. Stevens, Jr., MD, and William I. Toffler, MD, both of the Oregon Health & Science University, point to other actual or potential abuses in PAS-permissive states, including "physician shopping" to get around safeguards; nurse-assisted suicide without orders from a physician; and economic pressures to use PAS, such as Oregon Medicaid patients being denied cancer treatment but offered coverage for assisted suicide.7 Furthermore, an investigative piece by the Des Moines Register revealed that mandatory reporting requirements were not followed by hundreds of doctors in states where MAID/PAS is legal.8
4. In the US, only people with terminal or incurable illnesses are eligible for PAS.
Most PAS legislation applies to an adult with a terminal illness or condition predicted to have less than 6 months to live. In Oregon and Washington State, nearly identical criteria are interpreted to mean less than 6 months to live—specifically, without treatment. Thus, a healthy 20-year-old with insulin-dependent diabetes could be deemed “terminal” for the purpose of Oregon’s “Death with Dignity Act.”
So, too, patients refusing appropriate treatment may be deemed “terminal” under current interpretation of the Oregon law. Thus, a patient with anorexia nervosa who refused treatment could be eligible for PAS under Oregon law, even though she could recover with intensive therapy. As Swedish investigator Fabian Stahle observes, “This is in fact an alteration of the traditional meaning of the concept of ‘incurable.’”9
5. “Slippery slope” arguments against PAS are overblown. In European countries that allow PAS, there is no evidence that patients are being euthanized improperly.
People with non-terminal illnesses have been legally euthanized at their own request in several countries for nearly 15 years. This has included certain eligible patients who have only psychiatric disorders. In 2002, Belgium, the Netherlands, and Luxembourg removed any distinctions between terminal and non-terminal conditions—and between physical suffering and mental suffering—for legally permitted PAS. Between 2008 and 2014, more than 200 psychiatric patients were euthanized by their own request in the Netherlands (1% of all euthanasia in that country). Among them, 52% had a diagnosis of personality disorder, 56% refused 1 or more offered treatments, and 20% had never even had an inpatient stay (1 indication of previous treatment intensity). When asked the primary reason for seeking PAS/euthanasia, 66% cited “social isolation and loneliness.”
Despite the legal requirement for agreement between outside consultants, for 24% of psychiatric patients euthanized, at least 1 outside consultant disagreed.10-12
The US has not been immune to the slippery slope, either. For example, in Oregon, a psychiatrist opened a fee-for-service death clinic, where for $5,000, “terminally ill patients who are eligible to take advantage of…Oregon's suicide law can book a death that might look a lot like a wedding package.”13
6. The method of “assisted dying” now used in Oregon and other PAS-states assures the patient of a quick, peaceful death, without serious complications.
A peaceful death is by no means guaranteed using current methods of PAS, as a recent piece by Lo pointed out: 14 “Physicians who support PAD need to consider how to address the potential for adverse outcomes, including longer time to death than expected (up to 24 hours or more), awakening from unconsciousness, nausea, vomiting, and gasping.”
Data collected between 1998-2015 showed that the time between ingestion of lethal drugs and death ranged from 1 minute to more than 4 days. During this same period (1998-2015), 27 cases (out of 994) involved difficulty ingesting or regurgitating the drugs, and there were 6 known instances in which patients regained consciousness after ingesting the drugs. However, it is difficult to know the actual rate of drug-induced complications, since in the majority (54%) of cases between1998-2015, no health care professional was present to attend and observe the patient’s death.15
7. “Death with Dignity” all comes down to the patient’s autonomy, and the right of patients to end life on their terms.
In the first place, under current legislation permitting so-called medical aid in dying, the patient is completely dependent on the judgment, authorization, and prescriptive power of the physician—hardly a state of autonomy.1 Moreover, autonomy is only 1 of the 4 ‘cornerstones’ of medical ethics; the others are beneficence, non-malfeasance and justice. As Desai and Grossberg observe in their textbook on long-term care:
“The preeminence of autonomy as an ethical principle in the United States can sometimes lead health care providers to disregard other moral considerations and common sense when making clinical decisions…we strongly feel that the role of the medical profession is to understand but not to support such wishes [for physician-assisted death]. Every person’s life is valuable, irrespective of one’s physical and mental state, even when that person has ceased to deem life valuable.”16
8. Doctors who conscientiously oppose PAS are perfectly free to refuse participation in it.
In theory, the California guidelines state that "A healthcare provider who refuses to participate in activities under the act on the basis of conscience, morality or ethics cannot be subject to censure, discipline … or other penalty by a healthcare provider, professional association or organization," the guidelines say.17 However, prior to its PAS law being declared unconstitutional, physicians in California could be compelled to participate in PAS, under certain circumstances.
California's health department regulation requires a state facility to provide PAS. If the request is denied, the patient has a right to a judicial hearing on the matter. If the court determines the patient is qualified, the attending physician must write a prescription for lethal drugs.18 Moreover, there is evidence that physicians are sometimes pressured or intimidated by patients to assist in suicide.7
9. Terminally ill people who request MAID are not suicidal and don’t commit suicide. They are dying, and simply want “hastening” of an inevitable death. In contrast, genuinely suicidal people are not dying of a terminal condition, yet they want to die.
This argument plays fast and loose with language, logic, and law. In fact, it turns ordinary language on its head, thereby eliminating suicide by linguistic fiat. As the American Nursing Association states, “suicide is the act of taking one's own life,”19 regardless of the act’s context. There may indeed be different psychological profiles that distinguish suicide in the context of terminal illness from suicide in other contexts, but that does not overturn the ordinary language meaning of suicide. Thus, when a terminally ill patient (or any other person) knowingly and intentionally ingests a lethal drug, that act is, incontrovertibly, suicide.
Most suicides occur in the context of serious psychiatric illness. Yet patients who express suicidal ideation in the context of a condition such as major depression rarely want to die; rather, as numerous suicide prevention websites note, “Most suicidal people do not want to die. They are experiencing severe emotional pain, and are desperate for the pain to go away.” 20
10. People requesting PAS are carefully screened by mental health professionals to rule out depression.
Most PAS statutes modeled after the Oregon Death with Dignity statute do not require examination by a mental health professional, except when the participating physician is concerned and decides to do so. Specifically, “The patient is referred to a psychologist or psychiatrist if concern exists that the patient has a psychiatric disorder including depression that may impair judgment.”21
A study of the Oregon law concluded that “Although most terminally ill Oregonians who receive aid in dying do not have depressive disorders, the current practice of the Death with Dignity Act may fail to protect some patients whose choices are influenced by depression from receiving a prescription for a lethal drug.”21
In Oregon, 204 patients were prescribed lethal drugs in 2016 under the “Death with Dignity” statute, yet only 5 patients were referred for psychiatric or psychological evaluation.22
11. Doctors who participate in PAS are almost always comfortable doing so and rarely regret their decision.
Many doctors who have participated in euthanasia and/or PAS are adversely affected— emotionally and psychologically—by their experiences. In a structured, in-depth telephone interview survey of 38 US oncologists who reported participating in euthanasia or PAS, nearly a quarter of the physicians regretted their actions. Another 16% reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.23 For example, one physician felt so “burned out” that he moved from the city in which he was practicing to a small town. Similarly, reactions among European doctors suggest that PAS and euthanasia often provoke strong negative feelings.24
12. For terminally ill patients, the only means of achieving “death with dignity” is by taking a lethal drug prescribed by one’s doctor.
Only a small minority of persons with a terminal disease seek a physician’s prescription for a lethal drug. It is not clear why self-poisoning confers more dignity to one’s death than more traditional and much more common ways of dying. Many people who are dying choose to “bear with” their pain. Some seek hospice care and—in cases of severe, intractable pain—merit palliative sedation.25
Some choose voluntary stopping of eating and drinking (VSED), which, according to one study involving hospice nurses, results in a more satisfactory death than seen with PAS. In fact, “as compared with patients who died by physician-assisted suicide, those who stopped eating and drinking were rated by hospice nurses as suffering less and being more at peace in the last two weeks of life.”26
A form of VSED called ‘sallekhana’ has been practiced in the Jain religion for centuries and is regarded as an ethical and dignified means of achieving a “natural” death.27 Conclusion
The case for physician-assisted suicide legislation rests on a number of misconceptions, as regards the adequacy, safety, and application of existing PAS statutes. The best available evidence suggests that current practices under PAS statutes are not adequately monitored and do not adequately protect vulnerable populations, such as patients with clinical depression. The American College of Physicians,28 the American Medical Association, the World Medical Association and the American Nurses Association have all registered opposition to physician-assisted suicide.
It is critical that physicians inform themselves as regards the actual nature and function—or dysfunction—of medical aid in dying legislation. The first step is to recognize and challenge the many myths that surround these well-intended but misguided laws.
Acknowledgments
The authors wish to recognize the important contributions of Dr. Mark Komrad and Mr. Alex Schadenberg to the discussion of physician-assisted suicide.
Ronald W. Pies, MD is Professor Emeritus of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University, Syracuse, NY; and Clinical Professor of Psychiatry, Tufts U. School of Medicine, Boston. Annette Hanson, MD, is Director of the Forensic Psychiatry Fellowship Program, and Clinical Assistant Professor, Department of Psychiatry, University of Maryland School of Medicine.
References
Szasz T: Fatal Freedom. Syracuse University Press, 1995.
Loggers ET, Starks H, Shannon-Dudley M et al. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013 Apr 11;368(15):1417-24. https://www.nejm.org/doi/full/10.1056/NEJMsa1213398
Oregon board investigates failed assisted suicide. Jun 20, 2005 http://www.drugtopics.com/community-pharmacy/oregon-board-investigates-failed-assisted-suicide
The Oregon Death With Dignity Act: A Guidebook for Healthcare Providers, page 43. Accessed at: http://www.ohsu.edu/xd/education/continuing-education/center-for-ethics/ethics-outreach/upload/Oregon-Death-with-Dignity-Act-Guidebook.pdf
Hendin H, Foley K. Physician-Assisted Suicide in Oregon: A Medical Perspective, Mich. L. Rev. 106; 1613 (2008). Available at: https://repository.law.umich.edu/mlr/vol106/iss8/7
Suicide with a helping hand worries Iowans on both sides of 'right to die'. Desmoine Register, 2016 Nov 25 https://www.desmoinesregister.com/story/news/investigations/2016/11/25/too-weak-kill-herself-assistance-legal/92407392/
Stahle F. Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model. https://www.masscitizensforlife.org/oregon-health-authority-reveals-hidden-problems-with-the-oregon-assisted-suicide-model
Kim SYH, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362-368 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5530592/
Komrad MS. APA Position on Medical Euthanasia. Psychiatric Times. Feb. 25,c 2017. http://www.psychiatrictimes.com/suicide/apa-position-medical-euthanasia
Lo B. Beyond Legalization — Dilemmas Physicians Confront Regarding Aid in Dying.” N Engl J Med. 2018; 378(22):2060-2062 https://www.nejm.org/doi/10.1056/NEJMp1802218?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dwww.ncbi.nlm.nih.gov
California Code of Regulations. § 4601. Petitions to the Superior Court and Access to the End of Life Option Act. http://www.dsh.ca.gov/Publications/docs/Regulations/2016_10_31_End_of_Life_ISOR.pdf
Ganzini L, Goy ER, Dobscha SK. Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey BMJ 2008; 337:a1682 https://www.bmj.com/content/337/bmj.a1682
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(6):507–513. doi:10.1001/jama.280.6.507 https://jamanetwork.com/journals/jama/article-abstract/187854
Ganzini L, Goy ER, Miller LL et al. Nurses' experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med. 2003 Jul 24;349(4):359-65. https://www.nejm.org/doi/full/10.1056/NEJMsa035086
This article explains how the Oregon Health Plan rations care for patients with cancer.
Dr Kenneth Stevens
By Kenneth R. Stevens, Jr., MD
April 15, 2018
The Oregon Health Plan (Medicaid) uses a Prioritized List of Health Services (Link) established by the state Health Services Commission in determining what diagnoses, conditions and treatments will be covered. The Oregon Health Plan (OHP) was established in 1994.
It is currently under the Oregon Health Authority (OHA).
The OHP Guidelines for patients with serious illness have changed over the years.
During its early years (1994 to about 2008-2009), one of its guidelines was:
“It is the intent of the Commission to not cover diagnostic or curative care for the primary illness or care focused on active treatment of the primary illness which are intended to prolong life or alter disease progression for patients with a 5% chance of a 5 year survival.”
This was the criteria used to deny Barbara Wagner of Springfield, Oregon from receiving chemotherapy for her recurrent lung cancer.
Barbara Wagner’s story:
Barbara Wagner of Springfield, Oregon, a 64-year old great-grandmother was diagnosed with lung cancer in about 2006. Her cancer was initially treated with chemotherapy and radiation, and she went into remission. In early May 2008, a CT scan revealed her cancer was back and her cancer physician prescribed Tarceva (brand name erlotinib) a pill taken once a day for the purpose of slowing the cancer growth and extending her life. Studies show the drug provides a 30% increased median survival for patients with advanced lung cancer. One-year-survival rate for patients who took Tarceva increased by more than 45% compared to patients who took a placebo. She was on the Oregon Health Plan (Medicaid) and was notified in May 2008 that the OHP would not cover the beneficial chemotherapy treatment, “but that it would cover palliative, or comfort care, including, if she chose, doctor-assisted suicide.” She said she was devastated when she found that the Oregon Health Plan wouldn’t cover the cancer medication prescribed by her oncologist. “I think it’s messed up,” Wagner told the reporter, bursting into tears. (“A Gift of Treatment – When the Oregon Health Plan fails to cover a cancer drug, the drugmaker steps in” by Tim Christie, June 3, 2008, The Register-Guard Newspaper, Eugene, Oregon.)
She was particularly upset because the letter of denial said that doctor-assisted suicide would be covered! “To say to someone, we’ll pay for you to die, but not pay for you to live, it’s cruel,” she said. “I get angry. Who do they think they are?”
Barbara Wagner
Having been given no help or hope from the State of Oregon, her oncologist appealed to Genentech, the company that markets Tarceva in the United States, to cover Wagner’s medication. On Monday, June 2, she got the call from Genentech that they would cover the drug for a year, at which time she could re-apply. She was expecting delivery of the drug on June 3. “It’s fantastic”, she said, “I can’t wait to start the medication.” Ultimately, the drug company demonstrated more concern about Barbara’ continued survival than did the state of Oregon.
Mrs. Wagner died a few months later.
The Oregon Health Plan later changed the guidelines for patients like Barbara Wagner.
The guidelines for the January 1, 2010 OHP Prioritized List (revised 7-21-10) states:
Guideline Note 12. Treatment Of Cancer With Little Or No Benefit Near The End Of Life.
All patients receiving end of life care, either with the intent to prolong survival or with the intent to palliate symptoms, should have/be engaged with palliative care providers (for example, have a palliative care consult or be enrolled in a palliative care program).
Treatment with intent to prolong survival is not a covered service for patients with any of the following:
Median survival of less than 6 months with or without treatment, as supported by the best available published evidence.
Median survival with treatment of 6-12 months when the treatment is expected to improve median survival by less than 50%, as supported by the best available published evidence.
Median survival with treatment of more than 12 months when the treatment is expected to improve median survival by less than 30%, as supported by the best available published evidence.
Eastern Co-operative Oncology Group (ECOG) performance score of 3 or higher
The Health Services Commission is reluctant to place a strict $/QALY (quality adjusted life-year) or $/LYS (life-year saved) requirement on end-of-life treatments, as such measurements are only approximations and cannot take into account all of the merits of an individual case. However, cost must be taken into consideration when considering treatment options near the end of life. For example, in no instance can it justified to spend $100,000 in public resources to increase an individual’s expected survival by three months when hundreds of thousands of Oregonians are without any form of health insurance.
Treatment with the goal to palliate is addressed in Statement of Intent 1, Palliative Care.
The most recent guideline 3-22-2018 states:
Guideline Note 12, Treatment Of Cancer With Little Or No Benefit
Cancer is a complex group of diseases with treatments that vary depending on the specific subtype of cancer and the patient’s unique medical and social situation. Goals of appropriate cancer therapy can vary from intent to cure, disease burden reduction, disease stabilization and control of symptoms. Cancer care must always take place in the context of the patient’s support systems, overall heath, and core values. Patients should have access to appropriate peer-reviewed clinical trials of cancer therapies. A comprehensive multidisciplinary approach to treatment should be offered including palliative care services (see Statement Of Intent 1, Palliative Care).
Treatment with intent to prolong survival is not a covered service for patients who have progressive metastatic cancer with:
A) Severe co-morbidities unrelated to the cancer that result in significant impairment in two or more major organ systems which would affect efficacy and/or toxicity of therapy; OR B) A continued decline in spite of best available therapy with a non reversible Karnofsky Performance Status or Palliative Performance score of 3 or higher which are not due to a pre-existing disability.
Treatment with intent to relieve symptoms or improve quality of life are covered as defined in Statement Of Intent 1, Palliative Care:
Examples include:
A) Single-dose radiation therapy for painful bone metastases with the intent to relieve pain and improve quality of life. B) Surgical decompression for malignant bowel obstruction. C) Medication therapy such as chemotherapy with low toxicity/low side effect agents with the goal to decrease pain from bulky disease or other identified complications. Cost of chemotherapy and alternative medication(s) should be considered.
To quality for treatment coverage, the cancer patient must have a documented discussion about treatment goals, treatment prognosis and the side effects, and knowledge of the realistic expectations of treatment efficacy. This discussion may take place with the patient’s oncologist, primary care provider, or other health care provider, but preferably in a collaborative interdisciplinary care coordination discussion. Treatment must be provided via evidence-driven pathways (such as NCCN, ASCO, ASH, SBMT, or NIH Guidelines) when available.
