Oregon's Suicidal Approach to Health Care

Oregon seems to have found a surefire way to lower health care costs: Tell the patient you'll pay for drugs that will end her life, but not those that would extend her life.  Here's how it works:

In May 2008, 64-year-old retired school bus driver Barbara Wagner received bad news from her doctor.  She found out that her cancer, which had been in remission for two years, had returned.  Then, she got some good news.  Her doctor gave her a prescription that would likely slow the cancer's growth and extend her life.  She was relieved by the news and also by the fact that she had health care coverage through the Oregon Health Plan.

It didn't take long for her hopes to be dashed.  

Barbara Wagner was notified by letter that the Oregon Health Plan wouldn't cover her prescription.  But the letter didn't leave it at that.  It also notified her that, although it wouldn't cover her prescription, it would cover assisted suicide.

After Wagner's story appeared in the Eugene Register-Guard, the Oregon Health Plan acknowledged that it routinely sends similar letters to patients who have little chance of surviving more than five years, informing them that the health plan will pay for assisted suicide (euphemistically categorized as "comfort care"), but not for treatment that could help them live for months or years.

Certainly, spending $100 for deadly drugs is cost effective.  And, ever since the Oregon Death with Dignity Act transformed the crime of assisted suicide into a "medical treatment" more than ten years ago, it has been perfectly legal.   Oregon doctors prescribe lethal overdoses of drugs.  Pharmacists dispense them, sometimes with instructions to "take all of this with a light snack and alcohol to cause death."  Patients die after taking them.

On to Seattle

Now, an Oregon-style law is under consideration in Washington State.   After engineering passage of Oregon's Death with Dignity Act, assisted-suicide advocacy groups thought other states would rapidly adopt similar laws.   But they were wrong.  Because their attempts to pass Oregon-style laws in more than twenty states failed, the Portland-based Death with Dignity National Center (DDNC), along with Compassion & Choices (the former Hemlock Society), devised a plan in 2005 called "Oregon plus One" to break the logjam. It is based on the premise that, if  just one more state follows Oregon's lead, then other states will fall in line.

The plan was put into effect in early 2006.  In its 2007 annual report, the DDNC noted that it had spent a year "researching and collecting data to determine that state which is most likely to adopt a Death with Dignity law...Through these efforts we have identified Washington as the state."   (Note that the assisted-suicide group chose Washington.  Washingtonians were not in on the selection.)

After choosing Washington as the target state, the DDNC reported, "[W]e have never had such great odds of success as we have in Washington in 2008.  That is why we will be directing $1.5 million over the next year and a half to the efforts....Our organization is providing leadership, political strategy, and financial resources to this monumental effort." 

The political campaign was formally announced in late 2007 and, in mid-July 2008, Initiative 1000 (called the "Washington Death with Dignity Act," a measure virtually identical to Oregon's law) qualified for the 2008 general election ballot.  Its advocates contend that Oregon's ten-year experience demonstrates that a Death with Dignity law not only works well, but is actually a benefit to patients.  As proof they point to Oregon's annual official reports, to the law's "safeguards," and to studies in professional journals.

However, their claims are at best misleading.  For example, under Oregon's law doctors participating in assisted suicide must file reports with the state.  So the only physicians providing data for official annual reports are those who actually prescribe lethal drugs for patients.   First, they help the person commit suicide and, afterwards, they report whether their actions complied with the law.  Then, that information is used to formulate the state's official annual reports.  However, according to American Medical News, Oregon officials in charge of issuing the reports have conceded that "there's no way to know if additional deaths went unreported."  (The official number of reported assisted-suicide deaths in Oregon is 341.)

Indeed, the official summary accompanying one annual report noted that there is no way to know if information provided by the physicians is accurate or complete.  But, it stated, "[W]e, however, assume that doctors were being their usual careful and accurate selves." The reporting agency also acknowledged that it has no authority or funding to investigate the accuracy of those self-reports.

It would be nifty if the Internal Revenue Service allowed such unverified and unverifiable self-reporting.

The Oregon law's safeguards are equally problematic.  They contain enough loopholes to drive a hearse through them.   The safeguards certainly do have the appearance of being protective.  They deal with requests for assisted suicide, family notification, and counseling or psychological evaluation.   However, those safeguards are about as protective as the emperor's new clothes:

  • The oral requests, which must be separated by fifteen days, do not need to be witnessed. In fact, they don't even have to be made in person. They could be made by phone - even left on the physician's answering device. The written request must be witnessed, but it could be mailed or faxed to the doctor.
  • The law states that the physician is to "recommend that the patient notify next of kin," but family notification is not required. It is entirely possible that the first time family members find out that a loved one was contemplating suicide could be after the death has occurred.
  • Doctors can facilitate the suicides of mentally-ill or depressed patients without any prior counseling being provided. A psychiatric evaluation is required only if the physician believes that the mental illness or depression is causing impaired judgment. According to Oregon's latest official report, not one patient who died after taking the lethal drugs was referred for counseling prior to being given the prescription.

Additionally troubling are omissions in both Oregon's law and the Washington proposal.   For instance, doctor shopping is not prohibited.  If one physician refuses to prescribe assisted suicide because, for example, the patient is not competent to make an informed death request, that patient or a family member can go from doctor to doctor until finding one who will write the prescription.

Moreover, neither Oregon's law nor Washington's proposal has any type of protection for the patient once the prescription is written.  While the requests for assisted suicide are to be made knowingly and voluntarily, there is no provision that the patient must knowingly and voluntarily take the lethal drugs.  Dr. Katrina Hedberg, the lead author of most of Oregon's official reports, acknowledged that there is no assessment of patients after the prescribing is completed.  She said that the "law itself only provides for writing the prescription, not what happens afterwards."

Forcing Physicians to Lie

The Washington proposal, in a major departure from Oregon's law, adds a layer of unprecedented deception by forcing doctors to lie about the cause of death.  It requires that, when a patient dies after taking the prescription for assisted suicide, the physician "shall list the underlying terminal disease as the cause of death."   Washington State Medical Association president, Brian Wicks, M.D., described the requirement in a WSMA press release opposing the initiative:

Under I-1000, if a physician prescribes a lethal overdose, when that physician completes the death certificate, he or she is required - actually required - to list the underlying disease (say lung cancer) as the cause of death, even when the doctor knows full well that the patient died due to the suicidal overdose he or she prescribed. To my knowledge there's no other situation in medicine in which the death certificate is deliberately falsified - and in which this falsification is mandated by law.

Concerns about assisted suicide often are thrust aside by citing studies to bolster the benign nature of legalized assisted suicide.  Such studies are often far from un-biased as indicated by one that was released in late 2007, just as the Washington campaign formally got underway.  Published in the Journal of Medical Ethics, and widely reported in news articles across the country, it concluded that assisted suicide in Oregon is abuse free, even for vulnerable people.  (The basis for that conclusion was an examination of Oregon's official annual reports.)  Its principle author was Margaret Pabst Battin.  Battin, a University of Utah philosophy professor. is a longtime supporter of assisted suicide and a member of DDNC's advisory board - information not disclosed in either the journal article or the initial flurry of national media coverage. 

Thus, the "proof" for the benign nature of legal assisted suicide -- found in official annual reports, safeguards and studies --  is preposterous.  Assisted-suicide advocates take great umbrage when this is pointed out, as they do at any suggestion of assisted-suicide being used for cost containment.  Do assisted-suicide advocates intend this as a cost-containment measure?  Does it matter?   Did their intentions mean anything to Barbara Wagner?  Or does it really come down to recognizing that, even if its advocates don't intend to follow such a path, the force of economic gravity inevitably leads in this direction?

When all is said and done, it is not the intent of assisted-suicide supporters that matters.   Instead, it is the law's deadly content and the inevitable price that we would all pay for health care cost containment - Oregon style.

Rita L. Marker is an attorney and executive director of The International Task Force on Euthanasia and Assisted Suicide.
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