First published on Alex Schadenberg's Blog:
By 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
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
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 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.
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."
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.
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?" .
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.
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.
Dr. Kenneth R. Stevens, Jr., MD