Oregon sees fewer numbers of physician-assisted suicides
■ The percentage of patients receiving psychiatric referrals before they get a lethal prescription remained at 5%, unchanged from 2003.
By Andis Robeznieks — Posted April 4, 2005
Fewer lethal prescriptions were written in Oregon last year than in 2003, and fewer people took them under the auspices of the state's Death With Dignity Act, which allows physician-assisted suicide. But what has opponents of the law most concerned is the lower number of people receiving psychiatric treatment before receiving their prescriptions.
According to the Oregon Dept. of Human Services' recent report on physician-assisted suicide, 37 terminally ill Oregon residents committed suicide under the law in 2004, compared with 42 in 2003. Also, 60 lethal prescriptions were written in 2004 compared with 68 in 2003.
In all, 208 people have now used the law to hasten their deaths. Although there was a drop-off from the previous year, these were the second-highest totals recorded in the history of the practice, and assisted-suicide opponents point to many areas of concern.
"Physician-assisted suicide is not needed and not natural," said oncologist Ken Stevens, MD, vice president of the anti-assisted-suicide group Physicians for Compassionate Care.
The AMA is opposed to assisted suicide, calling it incompatible with the physician's role as a healer.
Dr. Stevens criticized the state's report as "inadequate and sloppy," and said there is no real monitoring of what happens when a patient dies, so the state must rely on second- and third-hand information.
To receive a lethal prescription, patients must be adult residents of Oregon, diagnosed by two physicians as having a terminal illness that will lead to death within six months, and capable of making medical decisions. If either physician believes a patient has a mental disorder, the patient must be referred for a psychological examination.
In 1998, 31% of the patients who took a lethal prescription received a psychiatric evaluation by a specialist. In 2003 and 2004, however, only 5% received such an evaluation.
"We're still concerned that only 5% of the patients have had psychiatric referrals," Dr. Stevens said. "The Oregon Death With Dignity Guidebook for Health Care Professionals recommends that all patients who ask about physician-assisted suicide get psychiatric evaluation."
In addition to describing the patients, the state report also listed physician data. Of the 40 doctors who wrote the 60 lethal prescriptions in 2004, the report stated that they were in practice for a median of 22 years (out of a range of six to 36 years), and medical specialties included family medicine (57%), oncology (22%) and internal medicine (8%). Fourteen percent were in other specialties.
Of the 40 physicians who wrote lethal prescriptions, the state reported that 28 wrote one, nine wrote two, one wrote three, one wrote four and one wrote seven.
Dr. Stevens said this shows evidence that the law isn't working as intended. Instead of patients receiving prescriptions from doctors with whom they have an established relationship, he said they are being steered toward physicians who are advocates for the assisted-suicide law.
Peter Rasmussen, MD, is one of those physicians. He says he has written several lethal prescriptions, but said he had decided a long time ago not to talk about absolute numbers.
Dr. Rasmussen said 75% of the patients who come to him regarding assisted suicide are people he has never seen before, but he said he spends a minimum of three hours with each patient -- either in multiple visits or by telephone conversation -- before writing the prescription.
"It's not a prescription mill where you see a patient one time and write a prescription -- at least in my hands," Dr. Rasmussen said. He said he writes the prescription on the day the patient decides to take it, rather than writing it in advance. "I like to be kept in the loop, and I'd like to be present."
Dr. Rasmussen acknowledged the decreasing number of psychiatric referrals for assisted-suicide patients, but said physicians who treat dying patients are getting better at identifying the patients who need them.
"In my practice as an oncologist and palliative care physician, most of my patients are exhibiting some signs and symptoms of depression because many of these overlap with being terminally ill," he said. "So it's always on the radar screen, and I would say that most oncologists and people who spend a lot of time with the terminally ill are getting good at picking up clinical depression."
Along with medical and religious organizations, people with disabilities are another group that opposes assisted suicide, and Dr. Rasmussen said he recognizes their concerns.
Specifically, organizations for the disabled point to the number of people who list being "a burden" as an underlying reason for hastening their deaths. In 2004, 14 patients ( 38%) listed that as a concern. In all, the report states that 74 of the 208 patients, or 36%, who have used the law in the last seven years listed concern about being a burden as a reason for going through with the process.
Dr. Rasmussen said if a patient of his is feeling this way because of a loss of physical capacity, "then we work on that and not on Death With Dignity."
"I think all involved in the Oregon law must recognize that we are on a slippery slope, and we have to be careful with every step," he said. "But just because it's a slippery slope doesn't mean we shouldn't go there."
In 2001, then-U.S. Attorney General John Ashcroft ruled that physician-assisted suicide was not a "legitimate medical practice" and said any doctors who write a lethal prescription would lose their federal authority to prescribe controlled substances.
The state -- with Dr. Rasmussen listed as a plaintiff -- filed a lawsuit to overturn Ashcroft's ruling and won. The Ninth U.S. Circuit of Appeals upheld the decision. The U.S. Dept. of Justice appealed again, and the U.S. Supreme Court agreed to review the case. Arguments are expected to be heard this fall.
Oregon is the only state where physician-assisted suicide is legal. Bills seeking to expand the practice were introduced in four states this year. Legislation was defeated in Arizona and Hawaii, while bills in California and Vermont are pending.