American experience with assisted suicide confirms slippery slope

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Public Discourse published an excellent article by Richard Doerflinger, where Doerflinger explains to jurisdictions, such as Great Britain, that the assisted suicide slippery slope in America is disturbingly genuine. Doerflinger, who has researched the issue of assisted suicide for many years is challenging an Economist editorial supporting assisted suicide. 

Doerflinger writes:

Permitting assisted suicide for terminally ill patients has been debated for many years in Great Britain, as in the U.S. and other countries. The Parliament has never approved such a law, but proponents think this year may give them a victory.

The respected London-based periodical The Economist, which has supported the idea since 2015, recently weighed in with an editorial that offers a convenient overview of the campaign for what the editors call “assisted dying.” While dismissing the idea of a “slippery slope” toward broader killing, their own arguments illustrate that slope.

Doerflinger states the argument made by the Economist:

They begin with a broad claim that Britons “should have the right to choose the manner and timing of their death.” On its face, this is an argument for a “right” to suicide for everyone. The article ends with a call for a right held by all “adults of sound mind who are enduring unbearable suffering with no prospect of recovery,” noting that many people “suffer terribly with a disease that is not terminal.” Suffering, of course, is also not restricted to people with an illness.

The editorial’s insistence that people have a right to “take matters into their own hands” also misstates the issue. This is not about legalizing efforts to cause one’s own death, which have long been seen as meriting counseling and treatment rather than punishment. It is about some people—especially members of what some of us still call “the healing professions”—helping to cause the death of other people.

The assisted suicide lobby opposes Oregon bill expanding the law to euthanasia.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

Oregon Senate

The Oregon legislature is currently debating assisted suicide bill Bill HB 2217 to expand the assisted suicide law and permit euthanasia (homicide) by redefining the term "self administer" to allow patients to take the lethal drugs into their body using any method, including an IV tube or injection. The bill states:

“Self-administer” means a qualified patient’s physical act of ingesting or delivering by another method medication to end his or her life in a humane and dignified manner.

The assisted suicide lobby, which supports euthanasia, recently came out against HB 2217 because of the complications related to IV tubes. Compassion and Choices stated in their letter to the Oregon Senate Judiciary Committee regarding HB 2217:

Allowing patients to self administer an IV is very different than allowing them to self administer medication through a feeding tube or a macy catheter. I can’t imagine that we want to risk botched deaths because we have allowed a law that would have patients administering medications through equipement they have no training to use. This is a risky proposition. The law, as written, does not protect patients from those risks. 

...Given this, we strongly oppose advancing this bill and ask the lawmakers in Oregon to please give sufficient time to draft legislation that achieves the goal of supporting patients in realizing a compassionate death.

* Oregon doctor speaks out about depressed patient who died by assisted suicide.

An article by Elizabeth Hayes published in the Oregon Business Journal on May 10, outlines how Dr Charles Blanke, an Oregon doctor who actively participates in assisted suicide plans to implement the new regulations under HB 2217. The article states:

Blanke is vetting the regimen with a team of anesthesiologists and pharmacists. He contemplates a multi-channel infusion pump that the patient would turn on by hitting a button with their hand, elbow or wrist. The drugs would be liquid, not gas.

Bioethicist, Richard Doerflinger challenged HB 2217 in his testimony to the Oregon Senate titled: Oregon HB 2217 greases the slippery slope from assisted suicide to euthanasia.

I reported in January that Kim Callinan, the CEO of Compassion and Choices, stated:

If lawmakers want to improve medical aid in dying laws, then let’s address the real problem: There are too many regulatory roadblocks already!  

Actually, the problem with assisted suicide and euthanasia laws are that they give death enthusiasts the right to kill you.

Oregon Bill HB 2217 greases the slippery slope from assisted suicide to euthanasia.

Written submission of Richard M. Doerflinger

To: Members, Oregon Senate

Re: Opposition to HB 2217 on “death with dignity”

Oregon Senate

May 2, 2019

I have analyzed legislative proposals on end-of-life issues for almost four decades, and I now live in Washington state which, like Oregon, has a law allowing “death with dignity.” HB 2217 would change Oregon law to more closely adhere to the wording of Washington’s 2008 law, requiring that the lethal dose be “self-administered” by the patient.

Requiring that the patient must “self-administer” the lethal drugs seems at first glance to be a new safeguard against lethal action by third parties – that is, against allowing assistance in suicide to blur over into homicide. But this first impression is extremely misleading.

As introduced, HB 2217 defined “self-administer” as “a qualified patient’s physical act of ingesting or delivering by another method medication to end his or her life in a humane and dignified manner” [amending 127.800]. (The Washington law also defines “self-administer” in terms of “ingesting.”) But dictionaries define “ingest” as “take (food, drink, or another substance) into the body by swallowing or absorbing it” (Oxford), “take in for or as if for digestion” (Merriam-Webster), “take food or drink into the body” (MacMillan). A common synonym is “swallow.” This is something passive, a way of receiving the drugs; it is not inconsistent with someone else placing or forcing the drugs into the patient’s body.

In a House committee, HB 2217 was amended so that “self-administer” means “a qualified patient’s affirmative, conscious and voluntary act to take into his or her body medication to end his or her life in a humane and dignified manner” (emphasis added). This only repeats the problem, since dictionaries define “ingesting” as “taking” a substance “into” one’s body as by swallowing it. (The original phrase about “delivering” the drugs by another method has been deleted, leaving “self-administer” to mean only swallowing or absorbing.)

Current Oregon law refers to the patient as “taking” the lethal drugs. For example, the patient request form has the patient sign a statement that “I understand the full import of this request and I expect to die when I take the medication to be prescribed” [127.897]. This was always ambiguous: Did it mean the patient simply “takes” the drugs into his or her body, as by swallowing? Or did it mean that the patient will be the only person engaged in introducing the drugs into his or her body? HB 2217 resolves the ambiguity in the direction of the former option: Anyone can provide the drugs, introduce them into the body, even insert them into the patient’s mouth; the patient need only “take them into” his or her body by swallowing or absorbing them.

The subheading of HB 2217 says that it “prohibits anyone other than patient from administering medication to end patient’s life in humane and dignified manner.” The opposite is the case. The bill contains no such prohibition, and certainly no penalties for doing such a thing. It takes the already ambiguous term “take” in current law, and changes it to refer only to “taking into one’s body” drugs that may be administered by anyone.

One might imagine that such involvement by others is prevented by the existing Oregon law’s rule of construction stating: “Nothing in 127.800 to 127.897 shall be construed to authorize a physician or any other person to end a patient’s life by lethal injection, mercy killing or active euthanasia. Actions taken in accordance with ORS 127.800 to 127.897 shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law” [ORS 127.880]. But this is also not the case.

The first sentence of this provision has an unclear meaning because these terms (lethal injection, mercy killing, active euthanasia) are not defined in the Oregon law. But in any case, the second sentence nullifies the first sentence, rendering this supposed safeguard circular and meaningless. If “self-administer” means to “take into” one’s body, then the patient is “self-administering” the drugs whenever he or she receives them into the body. In such a case the practice is legal under the Death with Dignity Act, and legally cannot be construed as a case of “lethal injection, mercy killing or active euthanasia.” This circular process simply sends us back to HB 2217’s new definition of “self-administer” in 127.800 creating the loophole.

Obviously this second sentence of the provision was always meant to present a euphemism for what is really going on in “death with dignity.” That sentence also says that actions taken in accordance with the Oregon law may not be construed as “assisted suicide” – although in physical fact they are exactly what everyone calls assisted suicide, and identical with what Oregon’s own law calls the Class B felony of “assisting another person to commit suicide” (ORS 163.193) whenever the victim falls outside the definitions of the Death with Dignity Act.

In short, the new definition in HB 2217 only seems to help ensure that people who actively help kill the patient will have a “safe harbor” from prosecution. As long as it is the patient who absorbs the drugs, those who took the patient’s life can claim that they were “self-administered.”

Perhaps it is a back-handed compliment to more traditional views against homicide that when legislators seek to authorize it, they feel more comfortable doing so by euphemism and misdirection. But we should all be candid about what is going on. HB 2217 greases the slippery slope from assisted suicide to homicide.

Richard M. Doerflinger is an Associate Scholar, Charlotte Lozier Institute; Vita Faculty Fellow, University of Notre Dame’s de Nicola Center for Ethics and Culture; Public Policy Fellow, National Catholic Bioethics Center 

Opposition to assisted suicide is strong in the US.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

In 2017, there were 26 states that were challenged by assisted suicide campaigns and all 26 states rejected it. This year 25 states have had assisted suicide bills in their legislatures and as of now, only Hawaii has passed the bill. Yet the theme that the media is portraying is that the assisted suicide lobby is gaining momentum, yet in reality the opposite remains true.

But there is more to the story. Richard Doerflinger, with the Lozier Institute recently examined the assisted suicide data in the US. Doerflinger explains how assisted suicide bills have been overwhelmingly defeated but also 10 states have added or strengthened laws preventing assisted suicide since 1997. Doerflinger commented:

This map shows the 42 states that ban assisted suicide without exception -- ten of which passed new laws against it SINCE Oregon's law took effect in 1997. Three of these states passed new laws in the last year -- Alabama and Utah passed new bans, and Ohio added criminal penalties to its 2003 law allowing for civil penalties. Another 32 states have retained their older statutes or common law bans despite the assisted suicide movement's repeated attempts against those policies. Meanwhile, four states (and DC) have acted to follow Oregon's lead in the last 20 years. So which side is widely portrayed in the press as having big momentum?

Similar data was published by Lozier last year with research by Dr Jacqueline Abernathy.

In the past few months, assisted suicide has been defeated in Connecticut, Massachusetts, Wisconsin, New Hampshire, while the South Dakota voter initiative failed to get the needed signatures and more importantly  Utah passed a bill criminalizing assisted suicide.

What has changed is the fact that the assisted suicide lobby is now working to expand assisted suicide laws. The Connecticut assisted suicide bill also legalized euthanasia. In Wisconsin and Massachusetts the assisted suicide bills require physicians to "do or refer", while the Delaware assisted suicide bill specifically approved people with disabilities.

Fabian Stahle, a researcher in Sweden, learned that the definition of "terminal disease" used by the Oregon Health Authority was wider than the regular definition of terminal disease and he confirmed that people who are chronically ill can be approved for assisted suicide in Oregon, even if they do not have a terminal disease when they refuse effective treatment.

The Oregon assisted suicide law, that all other assisted suicide bills are based upon, is designed to deceive.

Assisted suicide in Oregon: The reality.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Lozier institute has published a thorough analysis of the reality of assisted suicide in Oregon by Richard Doerflinger based on the Oregon Health Authorities 2017 assisted suicide report.

• 2017 Oregon assisted suicide report. The number of deaths increase again.

Doerflinger, who is an associate scholar with the Charlotte Lozier Institute and a Public Policy Fellow at the University of Notre Dame’s Center for Ethics and Culture, examines the report based on key themes.

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

Physicians, witnesses, and others involved in the process need not comply objectively with the law’s requirements, but only show “good faith” compliance, exempting physicians from their usual obligation not to be negligent. The prescribing physicians need not refer a patient for psychological evaluation even in a clear case of clinical depression — such referral is required only if the doctors think the patient’s depression causes “impaired judgment.” So if they agree with the patient’s judgment that he or she is better off dead, there is no referral. 

the Oregon system is tailor-made to conceal, not reveal, abuses. The physicians involved in prescribing the drugs are the only people allowed to file reports on these cases. The Oregon Health Authority itself says it has no legal warrant to do anything but take this self-reporting at face value. If other doctors found that the patient is not eligible for assisted suicide, patient or family can simply keep trying other doctors until they find one ardently committed enough to assisted suicide to sign the forms – and it is only that last doctor who files a report. So the very cases that most cry out for investigation – in which other doctors had concluded that this patient is not eligible to receive lethal drugs – are those in which the only report is most likely submitted by ideologically committed physicians inclined to ignore or conceal problems. Those physicians are then told by the state to falsify the death certificate, listing the underlying illness as cause of death, so there will be no autopsy or independent scrutiny. And after filing an annual report from which all identifying information has been removed, the state destroys the original reports.

As I have always stated, the Oregon assisted suicide law is designed to protect physicians who are willing to prescribe lethal drugs.

He then examines the data in the 2017 assisted suicide report:

In 2017, there were 218 lethal prescriptions written and 143 patients died from these drugs. The annual increase in deaths has accelerated in the last four years, with almost twice as many assisted suicides in 2017 (143) as in 2013 (73). 

Fourteen of the 2017 deaths were from drugs prescribed in previous years. So of the 218 prescriptions filled in 2017, as many as 89 lethal barbiturate overdoses (with instructions on how to use them to take a life) are in the population, and the state that authorized their distribution has no idea what became of them. In all, 1,967 lethal prescriptions have been written and at least 1,275 patients have died from these drugs, leaving a total of 692 lethal overdoses unaccounted for.

He then examines the issue of mental health and assisted suicide:

From 1998 to 2012, only 6% of patients on average were referred for evaluation; this went down to just under 4% in 2013-2016, then 3.5% in 2017. The state has not cited a single case out of 1,275 in which a patient was found ineligible for assisted suicide because an evaluation found depression or other mental condition impairing judgment. 

...The essential question, then, is this: What checks are there against depression or other mental condition, misuse of the drugs by others with their own agendas, subtle or overt coercion, etc., at the time of death? 

The answer is: There aren’t any.

He then examines the oversight of the Oregon assisted suicide act:

The only person who can report on the circumstances at that time is the prescribing physician, and that person was only present 16% of the time in 2017 (an average of 15% for all years). In past years, a health care provider other than the prescribing physician was present 27% of the time on average; in 2017 that is down to 13%. Thus in 2017 no health care provider was present 71% of the time. 

Since the prescribing doctor, who is required to self-report the act, is rarely present at the death, therefore there is little to no oversight of the law.

Doerflinger then examined the definition of “Incurable and irreversible” terminal illness in the Oregon law based on the recent research by a Swedish investigator who communicated with the Oregon Health Authority. Doerflinger states:

Fabian Stahle, a Swedish investigator who contacted a state health official in Oregon to clarify how the phrase “terminal disease” is interpreted by those who monitor the law’s implementation. He found that patients are eligible for assisted suicide if the two doctors think they are likely to die in six months without any treatment — even if they could have been cured by treatment, or could live for years or decades if treated. If the patient refuses potentially curative treatment (as a suicidally depressed patient, for example, may well do), or treatment is denied by someone else like the physician or a health insurance company, that patient becomes “terminal” and can receive lethal drugs. Essentially you are terminal if, by withholding treatment, you can be made terminal.

He then uncovers further issues with the terminal definition:

Overall, the time from first request for the drugs, to death from those drugs, has been as long as 1,009 days (over five times the projected life expectancy); in 2017 it was as long as 603 days. 

In 2017, some 77% of the patients had various forms of cancer. Others had chronic conditions with a less predictable trajectory toward death, such as cardiac and respiratory conditions found in many seniors, neurological conditions like ALS (Lou Gehrig’s disease), and even metabolic conditions like diabetes. In 2016 the list included “benign and uncertain” growths; overall, three patients have been found eligible for the lethal drugs although doctors listed no illness at all.

The next question that he examined was the issue of uncontrolled pain.

The reality is that pain, or even concern about future pain, ranks low on the reasons that patients cite for getting the lethal drugs. In 2017, only 21% cited this concern (compared to an average of 26% in past years). The most common reasons are being “less able to engage in activities making life enjoyable” (88%), “losing autonomy” (87%), and “loss of dignity” (67%), all of which could be cited by someone with a chronic illness or long-term disability that is not terminal. The most significant change is that in 2017, some 55% of patients (compared to an average of 42% in past years) say they are obtaining the lethal dose because they are a “burden on family, friends or caregivers” – a feeling easily communicated to patients by those other parties, and by the existence of a government policy singling them out for “assistance” in suicide.

Further to that he examined the problems with assisted suicide's

In 2017, at least two patients had seizures after ingesting the drugs. Overall, at least 25 patients (including one in 2017 and three in 2016) regurgitated some of the dose, and seven overall have regained consciousness and died later of natural causes. (Interestingly, there is no record of anyone choosing to go through this a second time.) For 638 patients, 101 of them in 2017, it is not known whether such complications occurred, presumably because the prescribing physician who filed the report was not present. The time period from ingesting the drugs to death is unknown in most cases; in the 40 cases where it is known in 2017, patients took as long as 21 hours to die, compared to nine hours in 2016, with an overall maximum of 101 hours (over four days). In 2017 it took as long as four hours for the patient to lose consciousness, compared to a maximum of one hour previously; this figure is not known for 105 of the 143 patients in 2017.

Finally he examined the issue of medical treatment options:

One significant change: In 2017, only 31% of the patients had private health insurance (compared to 54% in 2016), and 68% had only governmental insurance such as Medicaid and/or Medicare (compared to 45% the previous year). This is troubling in light of Oregon’s Medicaid rationing plan, which has been known to deny potentially life-prolonging treatment to patients while highlighting the availability of assisted suicide. 

Not that private health insurance is a guarantee against rationing. In 2017, Nevada physician Brian Callister revealed that he had sought approval from insurance companies in Oregon and California (the latter also having an Oregon-style law) for two patients he thought could be cured by a treatment available in those states – in both cases, he says, the companies refused coverage for the treatment but suggested that he consider assisted suicide.

Richard Doerflinger concluded his article by stating:

This is the updated reality of physician-assisted suicide in the state whose law is seen as a model for the nation. Chronically ill seniors, potentially victims of untreated depression and the impression that they have become a “burden” on others, are nudged to a premature death that may be more gruesome than they’ve been led to believe, with no one usually present at the time of death to check whether they are competent, badgered by others, or overtly coerced toward that death. This is what has become known as “death with dignity” in Oregon, and advocates are working to spread it to far more states.

Clearly, the theory of assisted suicide in Oregon and the reality are very different.

• Oregon's assisted suicides: The Up-To-Date Reality in 2017.

Always Care, Never Kill: How Physician-Assisted Suicide Endangers the Weak, Corrupts Medicine, Compromises the Family, and Violates Human Dignity and Equality

This research article was published by the Heritage Foundation on March 24, 2015.

Ryan Anderson

By Ryan T Anderson PhD

Abstract

Allowing physician-assisted suicide would be a grave mistake for four reasons. First, it would endanger the weak and vulnerable. Second, it would corrupt the practice of medicine and the doctor–patient relationship. Third, it would compromise the family and intergenerational commitments. And fourth, it would betray human dignity and equality before the law. Instead of helping people to kill themselves, we should offer them appropriate medical care and human presence. We should respond to suffering with true compassion and solidarity. Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill.

The Hippocratic Oath proclaims: “I will keep [the sick] from harm and injustice. I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect.”[1] This is an essential precept for a flourishing civil society. No one, especially a doctor, should be permitted to kill intentionally, or assist in killing intentionally, an innocent neighbor.

Human life need not be extended by every medical means possible, but a person should never be intentionally killed. Doctors may help their patients to die a dignified death from natural causes, but they should not kill their patients or help them to kill themselves. This is the reality that such euphemisms as “death with dignity” and “aid in dying” seek to conceal.

In 2015, at least 18 state legislatures and the District of Columbia are considering whether to allow physician-assisted suicide (PAS).[2] Legalizing physician-assisted suicide, however, would be a grave mistake because it would:

• Endanger the weak and vulnerable,
• Corrupt the practice of medicine and the doctor–patient relationship,
• Compromise the family and intergenerational commitments, and
• Betray human dignity and equality before the law.

First, PAS endangers the weak and marginalized in society. Where it has been allowed, safeguards purporting to minimize this risk have proved to be inadequate and have often been watered down or eliminated over time. People who deserve society’s assistance are instead offered accelerated death.

Second, PAS changes the culture in which medicine is practiced. It corrupts the profession of medicine by permitting the tools of healing to be used as techniques for killing. By the same token, PAS threatens to fundamentally distort the doctor–patient relationship because it reduces patients’ trust of doctors and doctors’ undivided commitment to the life and health of their patients. Moreover, the option of PAS would provide perverse incentives for insurance providers and the public and private financing of health care. Physician-assisted suicide offers a cheap, quick fix in a world of increasingly scarce health care resources.

Third, PAS would harm our entire culture, especially our family and intergenerational obligations. The temptation to view elderly or disabled family members as burdens will increase, as will the temptation for those family members to internalize this attitude and view themselves as burdens. Physician-assisted suicide undermines social solidarity and true compassion.

Fourth, PAS’s most profound injustice is that it violates human dignity and denies equality before the law. Every human being has intrinsic dignity and immeasurable worth. For our legal system to be coherent and just, the law must respect this dignity in everyone. It does so by taking all reasonable steps to prevent the innocent, of any age or condition, from being devalued and killed. Classifying a subgroup of people as legally eligible to be killed violates our nation’s commitment to equality before the law—showing profound disrespect for and callousness to those who will be judged to have lives no longer “worth living,” not least the frail elderly, the demented, and the disabled. No natural right to PAS exists, and arguments for such a right are incoherent: A legal system that allows assisted suicide abandons the natural right to life of all its citizens.

Instead of embracing PAS, we should respond to suffering with true compassion and solidarity. People seeking PAS typically suffer from depression or other mental illnesses, as well as simply from loneliness. Instead of helping them to kill themselves, we should offer them appropriate medical care and human presence. For those in physical pain, pain management and other palliative medicine can manage their symptoms effectively. For those for whom death is imminent, hospice care and fellowship can accompany them in their last days. Anything less falls short of what human dignity requires. The real challenge facing society is to make quality end-of-life care available to all.

Doctors should help their patients to die a dignified death of natural causes, not assist in killing. Physicians are always to care, never to kill. They properly seek to alleviate suffering, and it is reasonable to withhold or withdraw medical interventions that are not worthwhile. However, to judge that a patient’s life is not worthwhile and deliberately hasten his or her end is another thing altogether.

Citizens and policymakers need to resist the push by pressure groups, academic elites, and the media to sanction PAS. Recent experience with PAS both in the United States and in Europe suggests how problematic it is.

Endangering the Weak and Marginalized

To understand how PAS endangers the weak and marginalized, one must understand what PAS entails and where it leads. With PAS, a doctor prescribes the deadly drug, but the patient self-administers it. While most activists in the United States publicly call only for PAS, they have historically advocated not only PAS, but also euthanasia: the intentional killing of the patient by a doctor.

This is not surprising: The arguments for PAS are equally arguments for euthanasia. Neil Gorsuch, currently a federal judge, points out that some contemporary activists fault the movement for not being honest about where its arguments lead. He notes that legal theorist and New York University School of Law Professor Richard Epstein “has charged his fellow assisted suicide advocates who fail to endorse the legalization of euthanasia openly and explicitly with a ‘certain lack of courage.’”[3]

The logic of assisted suicide leads to euthanasia because if “compassion” demands that some patients be helped to kill themselves, it makes little sense to claim that only those who are capable of self-administering the deadly drugs be given this option. Should not those who are too disabled to kill themselves have their suffering ended by a lethal injection?

And what of those who are too disabled to request that their suffering be ended, such as infants or the demented? Why should they be denied the “benefit” of a hastened death? Does not “compassion” provide an even more compelling reason for a doctor to provide this release from suffering and indignity?[4] As Professor John Keown points out:

If compassion justified us in giving a lethal prescription to a terminally ill patient on request to end their suffering, it would equally justify us in giving them a lethal injection, particularly if they were physically unable to commit suicide. It would also justify us in giving a lethal injection to a terminally ill patient who was incapable of making a request.[5]

Judge Gorsuch notes that for the Dutch, “it is the physician’s assessment of the patient’s quality of life as ‘degrading’ or ‘deteriorating’ or ‘hopeless’ that stands as the ultimate justification for killing.”[6]

Although the Supreme Court of the United States has ruled in two unanimous decisions that there is no constitutional right to PAS, three states permit it by statute: Oregon, Washington, and Vermont.[7] Physician-assisted suicide and euthanasia are allowed in three European countries—the Netherlands, Belgium, and Luxembourg—and Switzerland allows assisted suicide.[8]

The evidence from these jurisdictions, particularly the Netherlands, which has over 30 years of experience, suggests that safeguards to ensure effective control have proved inadequate. In the Netherlands, several official, government-sponsored surveys have disclosed both that in thousands of cases, doctors have intentionally administered lethal injections to patients without a request and that in thousands of cases, they have failed to report cases to the authorities.[9]