Profession

Assisted-suicide numbers up in Oregon

■ Opponents are concerned about the lack of psychological evaluations and the number of prescriptions taken after a 6-month prognosis has been eclipsed.

By Andis Robeznieks — Posted April 5, 2004

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» Psych referrals down
» A steady climb
» Issue is slow in other states
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Record numbers of Oregon residents in 2003 received and took lethal prescriptions allowed by the state's Death With Dignity Act, permitting physician-assisted suicide, but these patients accounted for only one-seventh of 1% of all deaths in the state.

In all, 42 people used the law to hasten their deaths in 2003, and 67 lethal prescriptions were written, according to the sixth annual report released recently by the Oregon Dept. of Human Services. The previous highs, recorded in 2002, were 38 deaths and 58 prescriptions.

According to the report, 23 females and 19 males took the lethal prescriptions, all had insurance, 41 were white, 39 were enrolled in a hospice program, 35 had cancer and 32 had some college education.

Losing autonomy and not being able to engage in activities that made life enjoyable were common reasons cited for choosing assisted suicide.

The release of the report has become an annual ritual in Oregon, with opponents and supporters of assisted suicide simultaneously noting that the figures are either cause for alarm or proof that the law is being used as intended by a small number of people.

"The longer you keep an act in place, the more people become desensitized to it, and it no longer causes the appropriate righteous indignation," said William Toffler, MD, the national director of Physicians for Compassionate Care. "The report is not at all routine to me, and the closer you look, the uglier it gets."

Although he disagrees with their arguments, Peter Goodwin, MD, medical director of Compassion in Dying of Oregon, said he appreciates the presence of assisted-suicide opponents.

"I think the opposing physicians play a hugely important role, because -- in a sense -- they help to ensure the requirements of the law are fulfilled," said Dr. Goodwin, a family physician and associate professor emeritus at Oregon Health and Science University. "But as this process goes along, their concerns become more and more peripheral."

Some of the concerns voiced by opponents this year are whether people are getting the prescriptions sooner than they should, whether their judgment is impaired, and whether they are truly "dying with dignity."

State law requires that patients making a request be terminally ill adult Oregon residents whose physicians have determined that they have six months or less to live. If they believe patients have depression or some other mental disorder that may impair their judgment, physicians are obliged to send them to a specialist for a psychological evaluation.

Because two people took prescriptions they received in 2002 and one took a prescription received in 2001, Dr. Toffler worried that the 6-month prognosis requirement is being ignored.

He also is concerned about the falling percentage of assisted-suicide patients getting psychological evaluations. That number fell from 37% in 1999 to only 5% in 2003.

"According to the law, it's up to the docs' discretion," said state epidemiologist Mel Kohn, MD. "We haven't seen any indication that there has been a violation of the law."

Compassion in Dying of Oregon Executive Director George Eighmey said there are valid reasons for people with lethal prescriptions living past their 6-month prognosis. "The life expectancies fit the bell curve," he said. "It also shows that people cling to life and do not take the medication as soon as they get it."

Dr. Goodwin said this statistic also reflects how having the option of assisted suicide reduces patients' anxiety and allows them to live longer and fuller lives even when they know that death is inevitable.

"They say that we support assisted suicide, but that's not the case. What we support is choice at the end of life," Dr. Goodwin said.

"When they have the medication at the end of life and didn't take it, that is a triumph as far as we're concerned, because we enabled them to have a choice and helped them have a peaceful death."

ADDITIONAL INFORMATION

Psych referrals down

Oregon's Death With Dignity Act calls for physicians to refer patients who request a lethal prescription to a specialist for psychological evaluation if they believe the patient might be depressed or mentally impaired. Opponents of the law are concerned because the number of patients being referred has steadily decreased.

	Patients referred
1998	31%
1999	37%
2000	19%
2001	14%
2002	13%
2003	5%

Source: Mel Kohn, MD, Epidemiologist, Oregon Dept. of Human Services

A steady climb

In 2003, 42 Oregon physicians wrote 67 lethal prescriptions that were taken by 42 patients under the auspices of the state's Death With Dignity Act. Both the number of prescriptions written and the number taken were an increase from 2002 numbers.

	Prescriptions written	Assisted suicide deaths
1998	24	16
1999	33	27
2000	39	27
2001	44	21
2002	58	38
2003	67	42
Total	265	171

Note: Two deaths in 2002 were attributed to prescriptions written in 2001. Two deaths in 2003 were attributed to prescriptions written in 2002 and one written in 2001.

Source: Oregon Dept. of Human Services

Issue is slow in other states

Oregon remains the only state in the nation to allow physician-assisted suicide, but several states have debated the issue.

Alaska, Arizona, California, Hawaii, Michigan, Vermont, Wisconsin and Wyoming have had assisted-suicide bills introduced, with most lapsing before a vote was taken. "We've been effective so far in stopping it from spreading," said Oregon family physician William Toffler, MD. "Every prediction from the assisted-suicide camp was that it would be like dominoes."

Dr. Toffler, national director of Physicians for Compassionate Care, said his anti-assisted-suicide group now has 2,000 members, but physicians continue to be active on both sides of the debate.

The Vermont Medical Society engaged in prolonged and sometimes heated debate last fall before deciding to keep its policy of opposing any bill related to assisted suicide. Vermont's bills were referred to the Health and Welfare committees of the Vermont House and Senate last year and have not yet come up for a vote.

In Hawaii's Legislature, where an assisted-suicide bill passed a House committee last month and was sent back a few days later, the issue has been debated now for three years with varying degrees of intensity.

But there was not much debate in Wyoming, where an assisted suicide bill introduced this year was quickly defeated. Wyoming Medical Society Executive Director Wendy Curran said the bill had been introduced by a maverick legislator in a budget session where bills need a two-thirds vote to go forward. "This is not an issue that resonates across the state," Curran said.