Did the Massachusetts assisted suicide lobby change its tactic or are they just lying?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Massachusetts legislature

Last Friday, the Massachusetts Joint Committee on Public Health, sadly advanced assisted suicide bills S.1208 and H.1926. I do not think there is time, in this legislative session to pass these bills into law, but the fact that they passed in committee is concerning.

It is also concerning that a commentary that was published in a Massachusetts newspaper causes more confusion as to what assisted suicide is. The article titled: In support of passing death with dignity law states:

There is nothing mandatory in this bill. No doctor may prescribe terminal sedation (my emphasis) requested by a patient unless the patient:
■ is mentally capable, and not suffering from clinical depression or anxiety severe enough to impair his/her judgment;
■ can take the prescribed medication by him or herself;
■ has requested the medication orally and in writing, with two witnesses, one of whom cannot be included in the patient’s will;
■ has met with two physicians and one mental health professional who each attest first to the patient’s understanding and awareness of the full consequences of her/his request, and second to the diagnosis of a terminal illness that will in all likelihood end her/his life within six months.

First, terminal sedation is not assisted suicide. Terminal sedation is a medical act to sedate a person who is experiencing uncontrolled symptoms. Terminal sedation can be abused, by intentionally overdosing or by sedating a person and then dehydrating the person to death, nonetheless terminal sedation is not assisted suicide.

Assisted suicide is to intentionally prescribe lethal drugs, knowing that the person intends to use the lethal drug cocktail to die by suicide.

Is equating terminal sedation with assisted suicide a way to change the way assisted suicide is viewed?

Secondly, people who die by assisted suicide in Oregon, where assisted suicide has been legal for more than 20 years, are rarely sent for a psychological assessment, even though a study found that more than 25% of patients who request assisted suicide are experiencing depression or feelings of hopelessness. 

According to the 2019 Oregon assisted suicide report, that out of 188 reported assisted suicide deaths only one of those people were sent for a psychological assessment.

Finally, the assisted suicide lobby promotes assisted suicide as a "peaceful death." The fact is that many assisted suicide deaths are prolonged and painful deaths.

Legalizing assisted suicide gives doctors who agree to cause the death of patients complete legal protection for doing so.

There are many more problems with assisted suicide. We believe in caring, not killing.

12 Myths About Assisted Suicide and Medical Aid In Dying

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.

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References

1. Szasz T: Fatal Freedom. Syracuse University Press, 1995. 
2.  https://constitutioncenter.org/blog/does-the-constitution-protect-a-right-to-die
3. 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
4. Oregon board investigates failed assisted suicide. Jun 20, 2005 http://www.drugtopics.com/community-pharmacy/oregon-board-investigates-failed-assisted-suicide
5. 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
6. 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
7. Stevens KR, Toffler WI. Euthanasia and physician-assisted suicide. JAMA, 2016;316(15): 1599 https://jamanetwork.com/journals/jama/article-abstract/2569774
8. 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/
9. 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
10. 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/
11. Komrad MS. APA Position on Medical Euthanasia. Psychiatric Times. Feb. 25,c 2017.  http://www.psychiatrictimes.com/suicide/apa-position-medical-euthanasia
12. https://fatalflawsfilm.com
13. https://abcnews.go.com/Health/MindMoodNews/oregon-doctor-opens-death-clinic-physician-assisted-suicide/story?id=10994210
14. 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
15. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year19.pdf
16. Desai AK, Grossberg GT.  Psychiatric Consultation in Long-Term Care, Johns Hopkins University Press, 2010, p. 262.
17. McGreevy P. Guidelines issued for California's assisted suicide law http://www.latimes.com/politics/la-pol-sac-guidelines-california-assisted-suicide-law-20160120-story.html
18. 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
19. American Nurses Association. Position Statement. Euthanasia, Assisted Suicide, and Aid in Dying. April 24, 2013 https://www.nursingworld.org/~4af287/globalassets/docs/ana/ethics/euthanasia-assisted-suicideaid-in-dying_ps042513.pdf
20.  https://medicine.umich.edu/sites/default/files/content/downloads/macomb-county-cmh-holding-on-to-life-toolkit.pdf
21. 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
22. https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf
23. 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
24. Stevens KR Jr. Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians. Issues Law Med. 2006 Spring; 21(3):187-200. https://www.ncbi.nlm.nih.gov/pubmed/16676767
25. Statement on Palliative Sedation. Approved by the AAHPM Board of Directors on December 5, 2014 http://aahpm.org/positions/palliative-sedation
26. 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
27. Tukol JTK. Sallekhana. https://www.jainworld.com/education/seniors/senles15.htm
28. Sulmasy LS, Mueller PS. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med. 2017;167(8):576-578.  http://annals.org/aim/fullarticle/2654458/ethics-legalization-physician-assisted-suicide-american-college-physicians-position-paper

Dr Mark Komrad: Submission to New Zealand government committee

The submission by Dr Mark Komrad to the New Zealand Parliamentary Committee examining euthanasia and assisted suicide.

Dr Mark Komrad

Dr Mark Komrad I am submitting feedback to the New Zealand Parliament’s End of Life Bill. I am a psychiatrist and a medical ethicist in Baltimore, Maryland, USA on the faculty of Psychiatry at Johns Hopkins, University of Maryland, and the Sheppard Pratt Health Systems who has been engaged in the issue of assisted suicide and euthanasia, particularly in the case of psychiatric patients, in the U.S., Canada, and Europe.

• An important assumption underlying such assisted dying legislation is that physician-administered death is the only escape from unbearable suffering. This is not consistent with state-of-the-art palliative care, which includes a number of techniques, including but not limited to “terminal sedation,” in which consciousness is suppressed to the point where suffering is not experienced. Though there may be an increased risk of death from such a procedure, that is not the intention of the procedure. This and many other measures are quite effective at relieving suffering in a dignified and compassionate manner. If we kill patients as a means of relieving suffering, it undermines the entire enterprise of palliative care and will short circuit access, willingness, and even resources available for palliative care. This has happened in Belgium, where palliative care nurses are actually resigning, with the complaint that palliative care facilities are becoming “houses of euthanasia.” [https://tinyurl.com/y7kdh9ab , Caldwell, S. “Palliative care nurses quit ‘houses of euthanasia’” Catholic Herald, 18 Jan 2018] 

• The deep and millennia-old value that is “professed” by the profession of Medicine is to not kill in the name of healing. This was the unique feature of the very foundation of Medicine by Hippocrates, who made trainees swear an oath that they would “give no man a poison, nor counsel anyone else to do so.” This Hippocratic Oath is so core and fundamental to the ethos of medicine that it is still recited at medical school graduations to this day. Just as the teachings of Jesus were the foundational root out of which the mighty tree of Christianity grew, with all of its core value systems, this Hippocratic ethos was the root out of which the tree of Medicine has grown, and it is intimate to its fundamental substance as a profession. Although there is arguably a continuum between the role of “bringer of comfort” and “bringer of death,” society has a vested interest in maintaining the role of physicians as the “bringers of comfort.” Maintaining the “sterile field” in which physicians bring comfort, without deliberately killing, is crucial to the doctor - patient relationship. This is vital to how a physician thinks through possible options, the degree of devotion to helping the patient, and the willingness to sustain a field of support for a suffering patient. Compassion means “to suffer with.” Allowing doctors to kill patients can increase the unconscious temptation for doctors to avoid their venerable, age-old devotion to “suffering with.” 

• No country that has experimented with medically assisted dying has been able to hold the practice to patients at the end of life. None. That is the intention with which it begins. The living laboratories of The Netherlands and Belgium, which have had over 15 years of experience with this since their law was struck, have seen an inexorable slope. It began with those who are terminally-ill, by the nature of their illness. It progressed to those who produced a terminal condition by refusing chronic life-sustaining treatment (i.e. insulin). Then it slipped to the chronically and non terminally ill; then to the removal of distinctions between mental and physical suffering (thus opening the door to psychiatric conditions and unbearable lifestyles); then to those who are merely “tired of living” or feel they have a “completed life;” then to proxy consent for euthanasia of the incompetent, children, people on life support, and people suffering from dementia — by family members; then to “mercy killing” of those without capacity, by doctors who are unable to find consenting family members. Now there is the push for over-the-counter suicide pills in the Netherlands. Each of these steps has been widely documented. 

• Shifting suicide from a freedom to a right is a profound shift for any society. When suicide is made a right, rather than a freedom, it implies that there is a duty to enable people to fulfill that right. That means setting up a class of human beings who now has a duty to help people fulfill the right to suicide. Whoever has that duty is now vested with the mantel of “compassion,” “virtue,” and “healing” in the act of killing, however well-intentioned. The now-regretful pioneer of euthanasia in The Netherlands, Doudewijn Chabot M.D., seeing society’s inability to constrain euthanasia to its originally legislated applications has noted, “a culture has emerged in which performing euthanasia is considered to be virtuous behavior.” This is not only true for doctors, but this sense of virtue is also bestowed on those who choose assisted suicide. They are cast as heroic and noble, while those who continue to suffer are seen as partially responsible for their own continued suffering, because they rejected the death solution. There are widespread anecdotes of this attitude towards the chronically suffering, developing in Belgium, which I discovered in my research. 

• There is much evidence for “suicide contagion” as a consequence of ordinary suicide. Several studies in the U.S. and in the Netherlands have shown that the introduction of physician assisted suicide has not only failed to curb the “natural” suicide rate, but has also been associated with an acceleration of that rate. Whether there is a cause and effect relationship is still unknown. Assisted suicide has certainly done nothing to curtail “natural” suicide. However, there is an extraordinary dissonance in a society that engages in public health measures and messages to prevent suicide, while simultaneously designating a “special privilige” to certain groups to not just permit suicide, but to help provide for and abet that goal—by the same professionals (physicians) who are otherwise engaged in thwarting suicide in others. 

• Suicidal thinking is a very reliable indicator of a treatable psychiatric condition. Many medical conditions, particularly degenerative ones, are known to be highly associated with clinical depression, as part of the diseases themselves—independent of the degree of impairment (i.e. not just a result of “demoralization”). Research from Oregon shows that clinical depression is commonly missed by physicians who write assisted suicide prescriptions [missed up to 26% of the time: Ganzini, et al, Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey British Medical Journal 2008; 337 :a1682]. This is congruent with extensive literature showing that clinical depression is missed in about 1/3 of patients by primary care physicians. There is also literature showing that psychiatric treatment aborts suicidal wishes in a large proportion of people with terminal illness [Liebenluft, et. al “The Suicidal, Terminally Ill Patient with Depression” Psychosomatics, 29 (4), 379]. As elsewhere in the world, the proposed New Zealand law makes psychiatric evaluation optional, as part of the evaluation for medical ending of life. The evaluating physician personally determines the need for psychiatric evaluation. If such a referral is made, it is largely limited to assessment of capacity, and it carries no mandated psychiatric treatment attempt to qualify for assisted dying. In addition, even if there is psychiatric evaluation, a patient can refuse to give access to collateral records or informants to enable a fully accurate assessment. 

• Reports from the Oregon Health Authority [https://tinyurl.com/ybyh9w63, “Oregon Death with Dignity Act: Data Summary, Oregon Health Authority, Public Health Division, 2016] demonstrate that the primary reason people request physician assisted suicide is psychiatric: fear, hopelessness, despair, anxiety, and inability to conceive of how they will cope as their illness progresses. These are much more commonly motivating factors (90% of the time) for assisted suicide than actual physical pain or current debilitation. It is fear of the future. Often these emotions are in the setting of complex family dynamics, abandonment, impoverishment, and a wide variety of other psychosocial stresses that affect coping ability. These are common, fundamental psychiatric issues, and addressing them lies within the skill set of mental health professionals—independent of any particular psychiatric diagnosis. It is vital to not bypass state-of-the-art means of addressing these concerns with mental health care, rather than providing a civilization-changing shortcut to medically provisioned suicide in the face of these existential distresses. Of all kinds of health care however, mental health care is often the least accessible, due to stigma as well as comparatively underfunded resources. So these factors facilitate a path of lesser-resistance, should the assisted suicide option be opened. This puts those who are more emotionally vulnerable and most in need of mental health care at risk of short-circuiting mental health treatment. 

Also, see my complete lecture on this issue at:  https://tinyurl.com/yboe394m

Oregon doctor: My Personal Story – The importance of trust between patient and doctor

Dr. Kenneth R. Stevens, Jr. MD, Radiation Oncologist,

Professor Emeritus and former Department Chair, Radiation Oncology
Oregon Health & Science University, Portland, Oregon

President, Physicians for Compassionate Care Education Foundation www.pccef.org

Click here to download a printable version of this article for distribution.

I have been following the experience with legalized physician-assisted suicide in Oregon since 1994. I have been a cancer doctor for 49 years in Oregon, where physician-assisted suicide is legal. I am Professor Emeritus and former chair of the Department of Radiation Oncology at Oregon Health and Science University. I continue to care for patients. 

My Personal Story – The importance of trust between patient and doctor

Dr Kenneth Stevens

I first became involved with assisted-suicide in 1982, shortly before my first wife, Shannon, died of cancer. We had just made what would be her last visit with her doctor. As we were leaving the office, he said that he could provide her with an extra-large dose of pain medication. She said she did not need it because her pain was under control. As I helped her to the car, she said “Ken, he wants me to kill myself.”

It devastated her that her doctor, her trusted doctor, would suggest that she kill herself. Six days later, she peacefully died in our home without pain, and with dignity. I learned how assisted suicide destroys the trust between patient and doctor. Patients want support from their doctor, not encouragement for them to take their life, or have the doctor or others cause their death.

Physician’s Role

Physician assisted suicide is fundamentally incompatible with the physician’s role as healer, would be difficult or impossible to control, and would pose serious societal risks. [AMA Principles of Medical Ethics.]

Dr. Leon Cass, MD, wrote: 

“Even the most humane and conscientious physicians psychologically need protection against themselves and their weakness and arrogance, if they are to carefully for those who entrust themselves to them. A physician-friend who worked many years in hospice caring for dying patients explained it to me most convincingly: ‘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.’ My friend’s horror at the thought that he might be tempted to kill his patients, were he not enjoined from doing so, embodies a deep understanding of the medical ethic and its intrinsic limits.” 

[Cass, LR: “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, Edited by K Foley and H Hendin, Baltimore, Johns Hopkins University Press, 2002, p 30.]

Suicide

When a person expresses a desire to take their own life, society generally acts to protect him/her from committing suicide. However, when assisted suicide is legalized, society acts to assist that person in committing suicide. This is especially true for those who are seriously ill or have disabilities – they have lost society’s protection against suicide. The legalization of assisted suicide legally protects doctors who write prescriptions for lethal drugs, and family members who are involved. It is not designed to protect patients from others causing their death.

Assisted Suicide is Suicide – Beware of Deceitful & Dishonest Euphemisms

The strategies and methods of pro assisted suicide organizations are to use euphemisms. But assisted suicide is suicide. Both the Connecticut State Superior Court (June 2, 2010) and the New Mexico Supreme Court (June 30, 2016) have clarified that so-called “physician aid in dying” is assisted suicide and euthanasia.

Assisted suicide death certificates are falsified by assisted suicide doctors
In Oregon, doctors are instructed to put the underlying disease as the cause of death. But the reality is the person died from an overdose of drugs resulting in an assisted suicide. Doctors are directed to falsify the death certificate. This undermines transparency in the record and the ability to investigate suspicious overdose deaths.

Pain is Not the Issue

Both opponents and proponents of legalization of assisted suicide agree that pain is not the issue. Pain can be controlled. Uncontrolled pain in the terminally ill rarely occurs. In Oregon only a very small minority or patients dying of assisted suicide chose it because of fear of pain in the future. This was not because they were having current pain.

Assisted suicide encourages patients to throw away their lives. Assisted suicide is not necessarily for only those who are dying. Some patients with a prognosis of living less than six months may live much longer.

Photo of me with Jeanette Hall, 15 years 

after I talked her out of assisted suicide.

In Oregon, the assisted suicide law applies to patients predicted to have less than six months to live. This does not necessarily mean that they are dying.

In 2000, Jeanette Hall was my cancer patient. At our first meeting, Jeanette told me that she did not want to be treated, and that she was going to “do” our law, i.e., kill herself with a lethal dose of barbiturates. She had previously voted in favor of the law, and that was what she had decided. I informed her that her cancer was treatable and her prospects were good. She was not interested in treatment; she had made up her mind for the assisted suicide.

Her surgeon had previously informed her that without cancer treatment, she had only six months to a year to live, making her eligible for Oregon’s law. I asked her to return for weekly visits. On the third or fourth visit, I asked her about her family and learned that she had a son. I asked her how he would feel about her plan. A short time later she decided to be treated.

Five years later, Jeanette and I happened to be in the same restaurant. Excitedly, she came over to my table exclaiming, 

“Dr. Stevens you saved my life.”

For Jeanette, the mere presence of legal assisted suicide had steered her to suicide. She has now told me repeatedly that if I had believed in assisted suicide, she would be dead. (Link to article).

Patients may become eligible for assisted suicide by discontinuing treatment. For instance, a person with insulin-dependent diabetes may become eligible by discontinuing taking insulin.

I have treated many cancer patients who were told they had only a few weeks to a few months to live, who have lived much longer; some patients as long as 20 years after a “terminal” brain tumor diagnosis. See my paper: “Terminal Illness, What Does it Mean?” (Link to article).

Financial Incentive for Assisted Suicide

Barbara Wagner – “They will pay for me to die but won’t pay for me to live.”

In Oregon, the combination of legal assisted suicide and prioritized medical care based on prognosis has created a danger for my patients on the Oregon Health Plan (Medicaid). First, there is a financial incentive for patients to commit suicide: the Plan will cover the cost of assisted suicide. Second, the Plan will not necessarily cover the cost of treatment. The story of Barbara Wagner was publicized in Oregon in 2008. She was informed that the Oregon Health Plan Insurance would not approve and pay for her lung cancer medication, but they would pay for Comfort Care, which included assisted suicide. She told the TV reporters, “Who do they think they are? They will pay for me to die, but won’t pay for me to live.” (Link to report).

As medicine becomes more politicized, you will lose your choice. Insurance companies and government bureaucracies will decide what treatments you may receive. You may not qualify for the treatment that you want and that may benefit you.

Depression is the leading cause of suicide

Depression is the leading cause of suicide. Depression needs to be diagnosed and properly treated with counseling and medications. Oregon researchers (Ganzini – British Medical Journal) in 2008 reported that 25% of Oregonians requesting assisted suicide were depressed. Yet, in the past 7 years less than 2% (14 of 574) of Oregonians dying of assisted suicide had a psychiatric evaluation.

Oregon has a real problem with its High Suicide Rate

Oregon's government pays for assisted suicide, but does not pay for adult suicide prevention

Oregon has a regular suicide rate that is 140% of the national average, and has increased 20% since 2000 (assisted suicide started in 1998). In spite of a recognized need in prior years for an adult suicide prevention program, the Oregon Health Authority reported in 2015 that they do not have funding for, or support for, an adult suicide prevention program. Oregon state government is paying for assisted suicides (like Barbara Wagner), but is not paying for adult suicide prevention. How do you justify suicide prevention in a state that has legalized assisted suicide? What message does legalization of assisted suicide send to those who are considering suicide because of life’s problems? (Link to article).

Legalization of physician-assisted suicide does not result in a decrease in regular suicides.

Researchers have reported last year that “legalizing physician assisted suicide has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides.
(Jones DA, Paton, D. How does legalization of physician-assisted suicide affect rates of suicide?, South Med J. 2015; 108(10):599-604)

Lack of Oversight by Oregon Health Department

There is a serious problem with the Oregon Department of Health’s oversight of assisted suicide. Following a failed assisted suicide attempt in 2005 (David Pruiett), the Department of Human Services (DHS) stated that they had:

“no authority to investigate individual Death with Dignity cases – the law neither requires nor authorizes investigations from DHS“

Press Release from DHS on 3/4/2005”

The problems with the Oregon information is exemplified by the following: The 2011 year report (released in 2012) listed the underlying illness as “Unknown” for 3 patients. How can an “Unknown” diagnosis be terminal? Residence was “Unknown” for 3 patients. How can two doctors confirm that a patient is terminal when the diagnosis in “Unknown”. In the past 5 years (2009-2013) the prescribing doctor has been present for only 65 of the 574 (11%) assisted suicide deaths in Oregon. Yet, doctors are asked to describe what happened at that time. They have no knowledge. Doctors are not required to care for the patient once the prescription for lethal overdose has been written.

Abuses and Complications

When it is reported that there are no or few complications from assisted suicide in Oregon, the truth is that we don’t know the complication rate. The Oregon Health Department reported that of the 132 assisted suicide deaths in 2015, the complications were “unknown” for 105, two patients regurgitated (vomited), two had other complications (type not stated), and 23 had no complications. But complication information was “unknown” for 105 of those who died, because the physician or other health care provider was not present at the time of death.

Coterie of Insiders Runs the Program

The Compassion & Choices organization are associated with three-fourths of Oregon’s assisted suicide deaths. In Oregon in 2009, 57 of the 59 assisted suicide deaths were their clients. They know and control the information released to the public. The Oregonian newspaper editors correctly stated:

“A coterie of insiders runs the program with a handful of doctors & others deciding what the public may know.” 

The Oregonian newspaper editorial 9/20/2008.

As reported in The Oregonian newspaper in 2008, “The group promoting assisted suicide, so-called Compassion & Choices, are like the fox in the proverbial chicken coop; in this case the fox is reporting its version to the farmer regarding what is happening in the coop”, (Stevens, KR, Toffler, WL, Assisted Suicide: Conspiracy & Control, The Oregonian newspaper, 24 September 2008)

In Oregon patients are not getting the lethal prescriptions from their own doctor. They usually obtain the doctor information from Compassion & Choices doctors. Most of the prescriptions are concentrated in a small number of doctors.

From 2001 to 2007, 109 doctors (1% of Oregon doctors) wrote 271 fatal prescriptions for assisted suicide. Three doctors wrote 62 of those prescriptions (23% of prescriptions). Seventeen doctors wrote 165 of the 271 prescriptions (61% of prescriptions).
Hedberg, J Clin Ethics 2009:20:123-132

George Eighmey, C&C Exec Director, reported in The Oregonian newspaper in 2007 that he had been present and involved in over three dozen assisted suicide deaths; he is an attorney, he is not a doctor.

No safe harbor for patients

What is ahead for assisted suicide? What do proponents want? One of the things they want is no safe harbor for patients. They believe that doctors should be required to participate, or to have a duty to refer a patient to a doctor who will write a lethal prescription. They want no choice for doctors. Sue Porter, a leader of Compassion & Choices, has written in support of this policy. When I asked her why that “duty to refer” requirement was not written into the Oregon or Washington assisted suicide laws, she told me that the voters would not have voted in favor of the assisted suicide law. They use language to get the law passed, then they campaign to have the language changed to require doctors to participate, or to require them to have a “duty to refer” to a doctor who will write a prescription for lethal drugs.

In Summary

Physicians who care for patients should not order and direct their death through assisted suicide.

• 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 is dangerous because of insurance company and government financial incentives.
• 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.

The American Medical Association

Thank you for the opportunity to testify in opposition to the legalization of assisted suicide.

Dr. Kenneth R. Stevens, Jr., MD

Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia on Participating Physicians

Kenneth R. Stevens, Jr., M.D., FACR*

Abstract: This is a review and evaluation of medical and public literature regarding the reported emotional and psychological effects of participation in physician-assisted suicide (PAS) and euthanasia on the involved physicians.

Materials and Methods: Articles in medical journals, legislative investigations and the public press were obtained and reviewed to determine what has been reported regarding the effects on physicians who have been personally involved in PAS and euthanasia.

Results and Discussion: The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia.

Conclusion: Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences.

The report by The New York State Task Force on Life and the Law stated: 

"Many physicians and others who oppose assisted suicide and euthanasia believe that the practices undermine the integrity of medicine and the patient-physician relation-ship. Medicine is devoted to healing and the promotion of human wholeness; to use medical techniques in order to achieve death violates its fundamental values. Even in the absence of widespread abuse, some argue that allowing physicians to act as 'beneficent executioners' would undermine patients' trust, and change the way that both the public and physicians view medicine." 1

The counter-argument has been expressed by Margaret Battin and Timothy Quill, editors of a book favoring legalization of PAS. These PAS advocates have stated that there is no evidence that PAS "legalization would corrupt physicians and thus undermine the integrity of the medical profession," and that "there is substantial evidence to the contrary." 2

Purpose

When new treatments or procedures in medicine are developed, they are scrutinized to determine if there are adverse or harmful effects associated with them. In the same way, physician-assisted suicide and euthanasia deserve to be evaluated to determine if they have adverse or harmful effects. Instead of focusing on the involved patients, this investigation focuses on the reported effects on the doctors who are involved in assisted suicide and euthanasia.

This investigation's focus is to determine what has been reported regarding the following questions:

• What have been the emotional and psychological effects of participation in PAS and euthanasia on the involved doctors?

• What have they expressed to others regarding their experiences?

• Are physicians being pressured, intimidated or psychologically influenced to assist in suicide or perform euthanasia?

• What has happened to doctors who have written prescriptions? Have they continued to be involved with assisted suicide with other patients after the experience with the first patient or have they stopped their involvement?

Materials and Methods

Since the passage of Oregon's assisted suicide law in 1994, the author has gathered and archived articles from medical journals, legislative investigations, and the public press regarding assisted suicide and euthanasia. This collection of articles numbers into the thousands, including dozens of books on the subject. Other articles were identified and obtained using PubMed and the following search words: "euthanasia, assisted suicide, physicians, responses, psychological, emotional." These publications were reviewed and analyzed to obtain information regarding the above questions.

Results and Discussion

The Netherlands Doctors in the Netherlands who have had experience with assisted suicide and euthanasia, have expressed concerns regarding the effects on doctors. A report from the Netherlands stated: "Many physicians who had practiced euthanasia mentioned that they would be most reluctant to do so again." 3

Emanuel stated that "in a television program reporting a euthanasia case, the Dutch physician who performed euthanasia noted that: 'To kill someone is something far reaching and that is something that nags at your conscience. . . . I wonder what it would be like not to have these cases in my practice. Perhaps I would be a much more cheerful person.'"4

The American Medical News reported the following comments from Pieter Admiraal, a leader of Holland's euthanasia movement: "'You will never get accustomed to killing somebody. We are not trained to kill. With euthanasia, your nightmare comes true.'" 5

In 1995-96, 405 Dutch doctors were interviewed regarding their feelings after their most recent case of euthanasia, assisted suicide, life ending without an explicit request, and alleviation of pain and other symptoms with high doses of opioids. The percentage of doctors expressing feelings of discomfort were: 75% following euthanasia, 58% following assisted suicide, 34% following life ending without an explicit request, and 18% for alleviation of pain with high doses of opioids. Fifty percent of the euthanasias and 40% of the assisted suicides were followed by "burdensome" feelings; and 48% of the euthanasia and 49% of the assisted suicide cases were followed by emotional discomfort. The willingness to perform physician-assisted death again was 95% after euthanasia and 82% for life ending without an explicit request.6 The doctors sought support afterwards following 43% of the euthanasia cases and following 16% of cases involving ending life without an explicit request.

Evidence reported by the British House of Lords Select Committee on the Assisted Dying for the Terminally Bill in 2005 includes the following candid responses by Dutch physicians and ethicists to questions from the committee:

Q1250 Response by Dr. Legemaate: "No physician ever likes performing euthanasia."


Q1350 Question by Baroness Finlay: "The first time that you performed euthanasia, how did you feel about it as a clinician?"
Response by Dr. Van Coevorden: "Awful."


Q 1351 Response by Dr. Mensingh van Charente: "It is not a normal medical treatment. You are never used to it."


Q1535 Question by Baroness Finlay: "Looking after complex patients can be exhausting. It can be physically and emotionally exhausting. I certainly know of a case where a patient was almost pressured by the doctor, by being offered euthanasia. I wondered if that reflected the doctor's personal distress and whether you have come across cases where the doctor is thinking of euthanasia as the only solution?"
Response by Dr. Zylicz: "I was giving consultations in several situations like this, when the GP was calling me about a patient with gastrointestinal obstruction. He said, 'The problem is that the patient is refusing euthanasia.' I said, 'What happened?' He said, 'In the past, all these kinds of situations, when people were intractably vomiting, I solved by offering euthanasia. Now this patient does not want it, and I do not know what to do.' That was really striking. Providing euthanasia as a solution to every difficult problem in palliative care would completely change our knowledge and practice, and also the possibilities that we have . . . . This is my biggest concern in providing euthanasia and setting a norm of euthanasia in medicine: that it will inhibit the development of our learning from patients, because we will solve everything with euthanasia."


Q1539 Response by Professor Jochemsen: "I know from physicians who are opposed to performing euthanasia that they are afraid of saying so when applying for jobs and trying to find a post as a physician. In certain circumstances, that will make it much more difficult for them to get a job."


Q1580 Response by Dr. Jonquiere: "When I received a request for euthanasia and I hear this also from my colleagues - when a patient said, 'Doctor, this is unbearable for me. Please help me die,' the first reaction as a doctor is, 'Oh my God! A request again!' and I will find whatever I can to prevent it."


Q1585 Response by Dr. Jonquiere: "My point is that, because doctors find the request so difficult - the most difficult request you can get as a doctor - that, in itself, is the reason why they try to find whatever way they can not to do it."


Q 1735 Question by Baroness Finlay: "The doctors who have performed euthanasia have often described it, certainly initially, as being emotionally draining, emotionally difficult, and that they have taken some time off, have perhaps not worked the next day, to have a break and then to carry on working. Has that been your experience?


Response by Dr. de Graas: "It certainly has been, but I think that a lot is changing in that regard. The first letter of SCEN [Support Consultation Euthanasia Network] is the 's' for 'support,' and that is essential. Also as a nursing home physician confronted with euthanasia, I know that it is emotionally draining; but it is absolutely important to discuss it, not only with the SCEN doctor but with all your colleagues, to keep yourself healthy."


Q1736 Question by Baroness Finlay: "Do you think that it has become less stressful, as the process has become more developed over the time that you have had it?"


Response by Dr. de Grass: "For the individual physician it never becomes less stressful. That is absolutely impossible. What we are learning as a group, however, is that, before we become emotionally worn-out, there are a lot of possibilities to keep yourself in a good emotional state."7

These responses indicate the significant adverse emotional and psychological stress experienced and reported by Dutch physicians who are involved with euthanasia and PAS.

The United States 

Two surveys of physicians in the United States have examined and reported on the effects on physicians of performing PAS or euthanasia.8

In a structured in-depth telephone interview survey of randomly selected United States oncologists who reported participating in euthanasia or PAS, Emanuel reported 53% of physicians received comfort from having helped a patient with euthanasia or PAS, 24% regretted performing euthanasia or PAS, and 16% of the physicians reported that the emotional burden of performing euthanasia or PAS adversely affected their medical practice.9

In a mail survey of physicians who had acknowledged performing PAS or euthanasia, Meier reported the following responses pertaining to the most recent patient who had received a prescription for a lethal dose of medication or a lethal injection among the 81 physician respondents (47% were prescriptions, 53% were injections): 18% of the physicians reported being somewhat uncomfortable with their role in writing a prescription, and 6% were somewhat uncomfortable with the lethal injection. 10

The State of Oregon 

The first cases of legal PAS in Oregon occurred in 1998. In 2000, thirty-five Oregon physicians who had received requests for assisted suicide from patients were interviewed regarding their responses to such requests. Mixed feelings were expressed by the physicians. The authors noted: "Participation in assisted suicide required a large investment of time and had a strong emotional impact. . . . Even when they felt they had made appropriate choices, many physicians expressed uncertainty about how they would respond to requests in the future [as indicated by the responses from two physicians]:

'But my thoughts are about the fact that I know that it is a very difficult thing as a physician . . . . I wonder if I have the necessary emotional peace to continue to participate.' (Physician D)


'I find I can't turn off my feelings at work as easily . . . because it does go against what I wanted to do as a physician.' (Physician I)"11

Timothy Quill M.D., a published advocate for legalization of assisted suicide, wrote an invited editorial about this study. He noted the apparent lack of preparation for the personal emotional toll that such interactions had on the physicians.12

In 1998, the first year of Oregon's Death with Dignity Act, fourteen physicians wrote prescriptions for lethal medications for the fifteen patients who died from physician-assisted suicide. The annual report observed that: "For some of these physicians, the process of participating in physician-assisted suicide exacted a large emotional toll, as reflected by such comments as, 'It was an excruciating thing to do . . . it made me rethink life's priorities,' 'This was really hard on me, especially being there when he took the pills,' and 'This had a tremendous emotional impact.' Physicians also reported that their participation led to feelings of isolation. Several physicians expressed frustration that they were unable to share their experiences with others because they feared ostracism by patients and colleagues if they were known to have participated in physician-assisted suicide."13 This type of information regarding the emotional impact on the involved physicians has not been presented in subsequent Oregon annual reports.

A 1999 mail-survey of physicians' experiences with the Oregon Death with Dignity Act reported: "Some physicians who provided assistance with suicide under the Oregon Death with Dignity Act reported problems, including unwanted publicity, difficulty obtaining the lethal medication or a second opinion, difficulty understanding the requirements of the law, difficulties with hospice providers, not knowing the patient, or the absence of someone to discuss the situation with." "Four physicians expressed ambivalence about having provided assistance with the suicide, though two of the four noted that they had become less ambivalent over time. One of these physicians decided not to provide such assistance again."14

The emotional trauma experienced by some Oregon doctors is noted in the following responses obtained in Oregon in December 2004 by the British House of Lords committee:

Q766 Question by Baroness Finlay: "In a conversation after we had taken evidence this morning from David Hopkins, he said that, at the beginning, he had the feeling that doctors needed to tell the whole story because they were very traumatized by having been involved, but that, in the last year, that is not happening as they have become used to it. I wondered whether you felt that was echoed within your research."


Response by Dr. Goy: "Again, anecdotally, yes. This was a monumentally difficult experience for a doctor early on, even considering changing the direction of care from preserving life and extending life to helping someone end it. For many, they have done it maybe for one patient and cannot reconcile that they have done it and they are very uncomfortable with it."


Q767 Question by Baroness Finlay: "The Dutch experience is that often doctors take the next day off because they cannot cope with taking any clinical decisions at all."


Response by Ms. Glidewell: "Sometimes they are overwhelmed by the impact of this which is contrary to what they normally do."15

Dr. Peter Reagan's description of his experience with "Helen" was the first individual account in the medical literature of assisted suicide in Oregon.16 His account reveals his emotional and psychological concerns. As Helen was dying from his prescribed lethal medication "[t]he three of us [Dr. Reagan and Helen's son and daughter] sat around her bed talking quietly about the emotional struggle we'd each been through."17Regarding his thoughts and emotions leading up to writing the lethal prescription, Dr. Reagan wrote:

I had to accept that this really was going to happen. Of course I could choose not to participate. The thought of Helen dying so soon was almost too much to bear, and only slightly less difficult was the knowledge that many very reasonable people would consider aiding in her death a crime. On the other hand, I found even worse the thought of disappointing this family. If I backed out, they'd feel about me the way they had about their previous doctor, that I had strung them along, and in a way, insulted them.18

This is an example of a doctor feeling intimidated and coerced by the family and patient to participate in assisted suicide.

In writing about Helen's expressed appreciation for his role in the assisted suicide, Dr. Reagan wrote, "I thanked her and then turned away with my tangle of emotions." "That afternoon. . . I wrote the prescription for the 90 secobarbital. I hesitated at the signature and stared out the window. . . . I tried to imagine deciding to die. . . . Whenever I tried, I experienced a sadness much more profound than what I saw in her." "I slept badly."19

The extent of Dr. Reagan's personal concerns is exemplified by his editorial inclusion of the following: "Experience in the Netherlands suggests that doctors are profoundly affected by an act of physician-assisted suicide. Gerrit Kimsma, a Dutch family physician and medical ethicist, writes with colleagues that some professionals become dysfunctional and may require a lot of time to recover."20

Further insight into Dr. Reagan's experience is found in an earlier newspaper reporter's interview in 1998 of a then anonymous doctor whose story, matches that of "Helen" and Dr. Reagan:

Q: What did you learn from the experience?


A: I think the most important thing is for doctors to understand how huge of an experience it's going to be for them and that they must have ways of dealing with it for themselves.


Q: How did you feel the day that your patient planned to use the medication?


A: I would look out the window that day and try to imagine what it would feel like to take leave of the Earth that day - and it was a pretty nice day - and the sadness that that thought induced in me and I couldn't find it in my patient. And that was a profound experience.


Q: What about the death was a struggle for you?


A: A big piece is grief. A big piece is a funny sort of ambivalence where a person says, 'Really nice to have met you. Really nice to have gotten to know you a little better. Where's the medicine?' I have a feeling of responsibility that I can't say I'm entirely proud of. I did what I felt was right, given bad choices. But frankly, maybe I'm kidding myself a little bit, but it's better to not feel good about this. . . . I have to admit, I am blown away by how different this felt than a natural death. And I am still not clear on what to make of that. . . . Just the suddenness of it. It's shocking to have somebody go from telling a family story to being dead. It's a strange, strange, strange transition.21

Later in 1998, the same reporter noted, "Reagan still grapples with his experience. He has declined other requests from patients who weren't qualified. But if he meets another patient who is qualified, he will help. To him, it would feel like abandonment if he didn't."22 Dr. Reagan is expressing that he would have "no choice" and is an example of a doctor feeling intimidated by the patient and family to participate in assisted suicide.

In a newspaper interview in 2001, the same reporter wrote, "Dr. Peter Reagan, the primary physician in the first publicly described case in 1998, said the experience changed his feelings about assisted suicide. If he were dying, 'I made a commitment that I wouldn't ask my own doctor to help in this way,' Reagan said, 'because it's a lot to ask.'" 23Dr. Reagan described his troubled feelings in the reversal of his role as a healer, to his role in assisting Helen in her suicide. There is a sense of isolation. In Dr. Reagan's first comments to the public and press, he was concealed by anonymity. It was difficult for him to find others with whom to discuss his troubling experience.

Leon Cass stated that "the psychological burden of the license to kill (not to speak of the brutalization of the physician-killers) could very well be an intolerably high price to pay for physician-assisted euthanasia."24

The author of an investigation of "the euthanasia underground" reported:

The personal cost of involvement in illegal euthanasia was a central theme in interviews, and one emphasized throughout this book. 'I hate it', says one doctor, 'my partner hates it, because [she] feels that I'm going to be really horrible to be around . . . afterwards.' Another emphasized the 'emotionally demanding and draining' nature of involvement, adding 'there's only a finite amount of times you can do it' and 'I think I've almost reached the expiry date.' These are typical comments.25

Intimidation of and anger towards doctors who block access to PAS 

Hamilton and Hamilton reviewed the first case of legal assisted suicide in Oregon that was reported in the press.26 The physician who helped the ill woman end her life described the woman's tenacity and determination in her decision. "It was like talking to a locomotive. It was like talking to Superman when he's going after a train."27 The Hamiltons' psychiatric analysis of this case was that the doctor felt helpless when faced with the challenge of containing a patient who elicited images of locomotives, or of attempting to make a therapeutic intervention when talking with the patient seemed, as he put it, like "talking to Superman when he's going after a train."28 The doctor was expressing powerlessness on his part.

This intimidation of doctors by patients who request assisted suicide is also described in an analysis of in-depth personal interviews of thirty-five Oregon physicians who received a request for a lethal prescription.29 The article portrays a daunting situation for the doctors. These doctors describe very forceful patients who persevered in their requests for assisted suicide, even when the doctors were unwilling to participate. One doctor quoted a patient as saying, "I am going to come in and I am going to try to convince you."30 Another doctor said, "I learned very quickly that the patient's agenda is to get the medication. When I tried to talk them out of it, or to really assess their motivations, then they perceived me as obstructionist and became quite resentful of that."31

Emotional experiences for psychiatrists who are called upon to evaluate potential assisted suicide patients' mental competency, appear to be more profound when they disqualify patients. Dr. Linda Ganzini described the painful experience of two patients whom she [as the evaluating psychiatrist] disqualified for the option of Oregon's assisted suicide law.32She stated: "These disqualifications resulted in extraordinary pain and anger for both of the patients and their families, which interfered with much-needed opportunities to resolve other emotional issues."33 Pain and anger is directed towards and felt by the evaluating psychiatrist. Such anger was energetically expressed by Kate Cheney, an Oregon PAS patient, whose evaluating psychiatrist told her, "You can't make a decision for yourself and your life, because you are not in your right mind."34 Kate Cheney's angry response was "Get out of my house. I can't believe you can tell me something like this."35 The significant anger towards the evaluating psychiatrist who disqualified her from PAS continued in Kate Cheney's daughter, who reported this experience.36

What is known regarding the frequency of and numbers of assisted suicide cases per physician?
Meier reported in a national survey of physicians, that the median number of assisted suicide cases since entering practice was two (range 1-25) for the 3.3% of surveyed physicians who had written a prescription for a patient to use with the primary intention of ending his or her own life.37The median number of euthanasia (lethal injection) cases since entering practice was also two (range 1-150) for the 4.7% of surveyed physicians who had ever given a patient a lethal injection.38

Questions regarding physician involvement in assisted suicide in Oregon 
After seven years of legalized assisted suicide in Oregon, we should have answers to the following questions:

• What is the total number of physicians who have written prescriptions under Oregon's PAS law?
• What has been the pattern of prescribing? How many physicians have written only one prescription, and how many have written multiple prescriptions?
• Most importantly, are there physicians who have written prescriptions in earlier years, who are not now writing prescriptions? Why have they changed their minds, and are not now involved in assisted suicide?

The basic Oregon PAS data for the early years has been destroyed, as noted in the following personal communication: "Unfortunately, we are unable to provide any additional information than is currently available in our Annual Reports. Prior to 2001, we did collect the names of physicians who were participating. However, because of concerns about maintaining the confidentiality of participating physicians, we began using a numeric coding system in 2001. When we implemented this coding system, we destroyed the identifying data from the earlier years."39 This was also documented in the responses to Q592-4 by members of the Oregon Department of Human Services to the British House of Lords Select Committee in December 2004.40

Because this basic Oregon data was destroyed by personnel in the state agency, the answers to the above questions will never be known.

Information regarding physicians' participation in physician-assisted suicide from Oregon Health Division reports
From 1998 through 2004, 326 prescriptions for lethal drugs have been written and 208 have died under Oregon's PAS law.41

The only report from the state that has given the number of doctors prescribing from one year to the next was reported for the 1999 year: "In 1999, 22 physicians legally prescribed the 33 lethal doses of medication. Six of them also prescribed in 1998."42 This information has not been included in subsequent annual Oregon state reports.

Of the forty physicians who wrote prescriptions during 2004, twenty-eight wrote one prescription, nine wrote two prescriptions, one wrote three prescriptions, one wrote four prescriptions, and one wrote seven prescriptions.43 This was the first year that this type of information was provided in the state's annual report.44 However, a year earlier, a reporter from The Oregonian newspaper publicly reported the following information for the 2003 year, which he had personally obtained from the Oregon Department of Human Services: "Of the 42 doctors who wrote prescriptions for assisted suicide in 2003, 27 wrote one prescription, eight wrote two, six wrote three, and one doctor wrote 6 prescriptions."45 This information was not in the Oregon state annual report for that year.

Specific deficiencies in data from the annual Oregon reports are listed in Table 1. This missing information makes it impossible to provide answers to the previously noted questions.

During the first four years of legalized PAS in Oregon the prescribing physician was present at the time the patient took the lethal medication for 52% of the assisted suicides.46 However during the 2004 year, the prescribing physician was present for only 16% of the patients.47 Why are the physicians withdrawing from being present at the time of the assisted suicide?

The effect of countertransference in physician-assisted suicide 

Countertransference is defined as a phenomenon referring "to the attitudes and feelings, only partly conscious, of the analyst towards the patient,"48 Regarding the "rational" decision of physicians to assist in the ending of a person with a terminal illness, Dr. Glen O. Gabbard, a noted psychiatrist, has written:

Those decisions made by medical professionals, including psychiatrists, can never be entirely free of what we would broadly call countertransference issues. The doctor's own anxiety in the face of death, and even the hatred of the patient who does not want treatment or will not allow the doctor to be helpful, can influence a supposedly scientific or "rational" decision.49

Table 1
Information (and missing information) about assisted suicide in Oregon

Year	# of prescriptions written	# of doctors writing prescriptions for lethal drugs	# of these doctors (prior column) who had written prescriptions for lethal drugs in prior year/s	# of PAS deaths	# of doctors writing prescriptions for those who died from ingesting lethal drugs	# of these doctors (prior column) who had written prescriptions for lethal drugs in prior year/s
1998	24	*	No prior year	16	14 of 15 deaths in 1st years report	no prior year
1999	33	22	6	27	*	*
2000	39	*	*	27	22	*
2001	44	33	*	21	*	*
2002	58	33	*	38	*	*
2003	68	42	*	42	30	*
2004	60	40	*	37	* 26**	*
Total	326	*	*	208	*	*

* Information missing from reports.

** Personal communication, March 10, 2005.50
From the published annual reports, Oregon Department of Human Services, Office of Disease Prevention and Epidemiology. 51

The involvement of countertransference with assisted suicide has been evaluated by Varghese and Kelly.52 They report that:

[T]he subjective evaluation by a doctor of a patient's 'quality of life' and the role of such an evaluation in making end-of-life decisions of themselves raise significant countertransference issues. Inaccurately putting oneself 'in the patient's shoes' in order to make clinical decisions and evaluations of quality of life leave the patient vulnerable to the doctor's personal and unrecognized issues concerning illness, death and disability.53

They state that "[f]ortunately, the ethical code prohibits certain actions on the part of the doctor. In the absence of these prohibitions, the doctor's countertransference feelings about patients could put the public in grave danger."54 They conclude "Psychopathological factors in the doctor, including reactions to illness, death, and the failure of treatment, can influence the dying patient's end-of-life decision."55

Conclusion

Physician participation in assisted suicide or euthanasia may have a profound harmful emotional toll on the involved physicians. Doctors must take responsibility for causing the patient's death. There is a huge burden on conscience, tangled emotions and a large psychological toll on the participating physicians. Many physicians describe feelings of isolation. Published evidence indicates that some patients and others are pressuring and intimidating doctors to assist in suicides. Some doctors feel they have no choice but to be involved in assisted suicides. Oregon physicians are decreasingly present at the time of the assisted suicide. There is also great potential for physicians to be affected by countertransference issues in dealing with end-of-life care, and assisted suicide and euthanasia.

These significant adverse "side effects" on the doctors participating in assisted suicide and euthanasia need to be considered when discussing the pros and cons of legalization.

Kenneth Stevens

* Dr. Stevens is emeritus Professor and Emeritus Chairman, Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon; and Vice President of Physicians for Compassionate Care, www.pccef.org B.S., Utah State University, 1963; M.D., University of Utah, 1966. Comments may be addressed to Dr. Stevens at: kenneth.r.stevens@verizon.net

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1 new york state task force on life and the law, when death is sought, assisted suicide and euthanasia in the medical context 104 (1994).
2 M. P. Battin & T. E. Quill, False Dichotomy Versus Genuine Choice, in physician-assisted dying : the case for palliative care and patient choice 1 (M. P. Battin & T. E. Quill, eds. 2004). 
3 P. J. van der Maas et al., Euthanasia and Other Medical Decisions Concerning the End of Life, 338 LANCET 669, 673 (1991).
4 E. J. Emanuel et al., The Practice of Euthanasia and Physician-Assisted Suicide in the United States: Adherence to Proposed Safeguards and Effects on Physicians, 280 JAMA 507, 507 (1998).
5 D. M. Gianelli, Dutch Euthanasia Expert Critical of Oregon Approach, AM. MED. NEWS, Sept. 15, 1997.
6 I. Haverkate et al., The Emotional Impact on Physicians of Hastening the Death of a Patient, 175 MED. J. AUSTL. 519, 5 19-22 (2001). 
7 select committee on the assisted dying for terminally ill bill, ii assisted dying for the terminally ill bill [hl]: evidence 405, 423, 448-50, 461, 484 (London: The Stationery Office Ltd., 2005). 
8 Emanuel, supra note 4, at 507-13; D. E. Meier et al., A National Survey of Physician-Assisted Suicide and Euthanasia in the United States, 338 NEW ENG. J. MED. 1193, 1193-1201 (1998). 
9 Emanuel, supra note 4, at 511. 
10 Meier, supra note 8, at 1197. 
11 S. K. Dobscha et al., Oregon Physicians'Responses to Requests for Assisted Suicide: A Qualitative Study, 7 J. PaLLiative Med. 451, 455, 457 (2004). 
12 T. E. Quill, Opening the Black Box: Physicians'Inner Responses to Patients'Requests for Physician-Assisted Death, 7 J. PaLLiative Med. 469, 469 (2004). 
13 A. E. Chin et al., Legalized Physician-Assisted Suicide in Oregon-The First Year's Experience, 340 NEW ENG.J. MED. 577, 583 (1999). 
14 L. Ganzini et al., Physicians'Experiences Withthe Oregon Death With Dignity Act,342 NEW ENG. J. MED. 557, 562 (2000). 
15 select committee on the assis ted dying for terminally ill bill, supra note 7, at 190-91. 
16 P. Reagan,Helen, 353 LANCET 1265, 1265-67 (1999). 
17 Id. at 1265. 
18 Id. at 1266. 
19 Id. 
20 asking to die: inside the dutch debate about euthanasia 29 1-93 (G. Kinsma & D. Thomasma, eds. 1998). 
21 Erin Hoover, Doctor Who Assisted Suicide Shocked by the Suddenness, oregonian, June 14, 1998, at C2. 
22 Erin Hoover Barnett, Suicide Law Still Draws Emotional Responses, oregonian, Dec. 28, 1998 (Erin Hoover and Erin Hoover Barnett are the same person). 
23 Erin Hoover Barnett, Oregon's Assisted-Suicide Law Inspires Better Care, Many Doctors Say, oregonian, Nov. 14, 2001, at E13. 
24 L. R. 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 17, 30 (K. Floey & H. Hendin, eds. 2002). 
25 r. s. magnusson, angels of death, exploring the euthanasia underground 242-43 (Melbourne U. Press, 2002). 
26 N. G. Hamilton & C. A. Hamilton, Therapeutic Response to Assisted Suicide Request,63 BULL. MENNIGER CLINIC 191, 191-201 (1999). 
27 Id. at 196.
28 Id. at 196-97.
29 L. Ganzini et al., Oregon Physicians'Perception of Patients Who Request Assisted Suicide and Their Families, 6 J. PALLIATIVE MED. 381-90 (2003).
30 Id. at 384.
31 Id. 
32 L. Ganzini & S. K. Dobscha, Clarifying Distinctions Between Contemplating and Completing Physician-Assisted Suicide, 15 J. CLINICAL ETHICS 119, 121 (2004). 
33 Id.
34 B. C. Lee, compassion in dying 77 (2003) (As related by Kate Cheney's daughter, Erika, in chapter entitled "Kate Cheney"). 
35Id.
36Id.
37 Meier, supra note 8, at 1193-1201.
38Id.
39 Letter from D. Niemeyer, Oregon Department of Human Services, to author (Feb. 17, 2004) (on file with author).
40 select committee on the assisted dying for terminally ill bill, supra note 7, at 262.
41 Chin, supra note 13; a. d. sullivan et al., oregon's death with dignity act: the second year's experience (oregon health div., 2000); oregon health div., oregon's death with dignity act: three years of legalized physician-assisted suicide (2001); oregon department of human services, office of disease prevention and epidemiology, fourth annual report on oregon's death with dignity act (2002); oregon department of human services, office of disease prevention and epidemiology, fifth annual report on oregon's death with dignity act (2003); oregon department of human services, office of disease prevention and epidemiology, sixth annual report on oregon's death with dignity act (2004); oregon department of human services, office of disease prevention and epidemiology, seventh annual report on oregon's death with dignity act (2005). 
42 SULLIVAN, id., at 9.
43 SEVENTH ANNUAL REPORT, supra note 41 at 14.
44 Id.
45 D. Colburn, Assisted Suicide Total Edges Higher in 2003, OREGONIAN, Mar. 10, 2004, at E1. 
46 FOURTH ANNUAL REPORT, supra note 41, at 16. 
47 SEVENTH ANNUAL REPORT, supra note 41, at 24. 
48 PSYCHOANALYTIC TERMS AND CONCEPTS 29 (B. Moore & B.Fine, eds., 1968). 
49 Foreward, 18:1 COUNTERTRANSFERENCE ISSUES IN PSYCHIATRIC TREATMENT: REVIEW OF PSYCHIATRY xiii-xvi (G. O. Gabbard, ed. 1999). 
50 Personal e-mail from D. Niemeyer to author (Mar. 10, 2005) (on file with author). 
51 Chin, supra note 13; SULLIVAN, OREGON HEALTH DIVISION SECOND ANNUAL REPORT, supra note 41; OREGON HEALTH DIV., supra note 41; FOURTH ANNUAL REPORT, supra note 41; FIFTH ANNUAL REPORT, supra note 41; SIXTH ANNUAL REPORT, supra note 41; SEVENTH ANNUAL REPORT, supra note 41. 
52 F. T. Varghese & B. Kelly, Countertranference and Assisted Suicide, in 18:1 COUNTERTRANSFERENCE ISSUES IN PSYCHIATRIC TREATMENT: REVIEW OF PSYCHIATRY 85 (G. O. Gabbard, ed. 1999). 
53 Id. at 92.
54 Id. at 106. 
55 Id. at 112.