Oregon’s second assisted-suicide report: Not the whole story
For the second year, the Oregon Health Division (OHD) has released an
official assisted-suicide report that is more notable for the information omitted than the information contained in the document.Under Oregon’s Death with Dignity Act — the 1997 law making Oregon the only jurisdiction in the world to formally legalize physician-assisted suicide (PAS) — the OHD is required to monitor and collect data on the implementation of the law. The OHD does this by reviewing reports which physicians submit once they have written a prescription for lethal drugs.
The OHD then "periodically" searches its Vital Records files "for death certificates that correspond to physician reports." If there’s a match, the doctor is contacted by phone and interviewed about certain details not contained on the standard physician reporting form or on the death certificate.
The OHD does "not interview or collect any information from patients prior to their death [sic]." [OHD, "Oregon’s Death with Dignity Act: The Second Year’s Experience," 2/23/00, p. 7. Hereafter cited as OHD Second Report.]
What’s in the report Using the data collected, the OHD issues an annual statistical report as mandated by the PAS law. Both the first report (on 1998 PAS deaths) and the second report (on 1999 PAS deaths) were released as official state documents, and a published version appeared in the New England Journal of Medicine (NEJM) on 2/18/99 and 2/24/00, respectively. (For information on the first year’s report, see Update, 1-3/99.)According to the latest report, a total of 33 people received prescriptions for lethal drugs in 1999. Of those, 26 died as a result of the drugs, 5 died from their underlying disease or illness, and 2 did not die before January 1, 2000. Additionally, there was one patient who obtained the deadly drugs in 1998, but didn’t ingest them until 1999. A total of 27 patients, therefore, died under the PAS law in its second year of implementation. Adding the 16 people whom the OHD identified as PAS deaths in the first year, the total reported body count now stands at 43. [Sullivan et al., "Legalized Physician-Assisted Suicide in Oregon — The Second Year," NEJM, 2/24/00, p. 598. Hereafter cited as NEJM Second Report.]
The median age of the 27 people who died in 1999 was 71. The majority were white, married, and educated. Sixteen (16) were men; 11 were women. Most (17) had cancer, while 10 had an assortment of illnesses, including ALS, chronic obstructive pulmonary disease, and AIDS. Eighteen (18) had private health insurance, 4 had Medicare only, and 4 were enrolled in Oregon Medicaid, a health care rationing program for the poor which covers assisted suicide (under the category "comfort care") but does not cover 169 other listed medical treatments or services. [NEJM Second Report, Table 1, p. 600, and Table 2, p. 602]
Because of criticism leveled at the OHD after the first-year report’s release, state researchers decided to add interviews with close relatives and friends of patients who died between 9/15/98 and 10/15/99 instead of just relying on case accounts provided by the death-prescribing doctors. While it might appear that these added interviews would provide a means to double check the doctors’ stories, the OHD undermined even the appearance of investigative objectivity by relying solely on the prescribing doctor or other provider involved with the patient’s PAS death to hand pick "the most appropriate family member to interview (one per patient)." Only the family member or friend of 19 PAS victims were interviewed, and all those interviews were conducted "within approximately one year after death." [NEJM Second Report, pp. 599-600; OHD Second Report, pp. 8 & 10]
Based on these interviews and doctors’ reports, the OHD concluded that, for the second year, all the death-prescribing doctors complied with the PAS law’s provisions and safeguards. Moreover, any concerns about "poverty, lack of education or health insurance, and poor care at the end of life" were unfounded since none of these factors contributed to patients’ opting for death. Like the previous year, the primary reasons doctors cited for patients’ choosing PAS were concerns and fears over loss of autonomy, being a burden on others, loss of control over bodily functions, inability to do things that make life enjoyable, and the wish to control the time and manner of death. According to the OHD, palliative care was available to all the PAS victims, and three quarters of them had hospice care before they died. [NEJM Second Report, pp. 602-603; OHD Second Report, p. 12]
It would be a mistake to assess Oregon’s experience with assisted suicide solely on the OHD’s official reports. Flaws in the law and reporting process, along with missing data, raise serious questions about the reports’ accuracy and objectivity.
The OHD has acknowledged that the data upon which its reports are based may be incomplete and inaccurate. While the OHD requires doctors to report all cases in which they write prescriptions for lethal drugs, the law contains no penalties for doctors or other health care providers who do not file reports with the state. Furthermore, the PAS law grants no regulatory authority to the OHD to ensure that doctors and providers comply with the reporting requirements.In the first report on 1998 PAS deaths, OHD researchers wrote that it was "difficult, if not impossible, to detect accurately and comment on underreporting." "We cannot determine," they explained, "whether physician-assisted suicide is being practiced outside the framework of the [PAS law]." [Chin et al., "Legalized Physician-Assisted Suicide in Oregon—The First Year’s Experience," NEJM, 2/18/99, p. 583]
In the most recent report, OHD researchers again acknowledged the problem with doctors who do not comply with the reporting requirements or the PAS law. "Underreporting cannot be assessed," they wrote, "and non-compliance is difficult to assess because of the possible repercussions for noncompliant physicians reporting data to the division." [NEJM Second Report, p.603]
The OHD is very selective about its data sources. The only doctors interviewed were those who had reported that they had written prescriptions for lethal drugs. Moreover, the OHD has admitted that it assumes these doctors are of good will and completely truthful. [OHD, "CD Summary," 3/16/99] Other physicians who, for good reasons, had determined that certain patients did not qualify for PAS under the law were never interviewed. Also, as stated earlier, the only other people questioned were one family member or friend for each of 19 selected PAS victims — a family member or friend recommended to the OHD by the death-prescribing doctor in each case. Neither of the OHD’s two annual reports cited any cases where patients could not self-administer the deadly drugs, where patients with impaired mental capacity obtained PAS prescriptions contrary to the law, or where troubling complications or symptoms arose during the PAS dying process. Yet, three such 1999 PAS cases were documented in news reports and articles, cases which were either not reported to the OHD or possibly omitted or overlooked by researchers.The first case was the subject of two feature articles published in the Oregonian, Oregon’s largest paper. ALS patient Patrick Matheny, 43, received his lethal drugs by Federal Express. When he attempted to self-administer them, he experienced difficulty. His brother-in-law, Joe Hayes, said that he had to "help" Matheny to die. "It doesn’t go smoothly for everyone," Hayes explained. "For Pat it was a huge problem. It would have not worked without help," he said. [Oregonian, 3/11/99]
This case prompted Oregon Deputy Attorney General David Schuman to offer the opinion that the PAS law discriminates against patients too disabled to legally self-administer the deadly dose. [See Update, 1-3/99]
The second unmentioned case was also reported in the Oregonian. Kate Cheney, 85, had cancer and requested PAS. Her doctor, suspecting that Cheney suffered from dementia, refused to give her the lethal drugs. Instead, he referred her to a psychiatrist, who, in turn, found that Cheney had lost her short-term memory. But the psychiatrist also noticed something else: Cheney’s daughter, who had accompanied her mother, seemed to be the one pushing for PAS for her mother.
The psychiatrist wrote in his records that Cheney lacked the "very high capacity required to weigh options about assisted suicide." He agreed with Cheney’s doctor that she did not qualify under the PAS law. But her daughter insisted on another opinion, and Kaiser, Cheney’s HMO, granted the request. This time she was referred to a psychologist, who also noted Cheney’s dementia and the pressure exerted by the daughter, but approved PAS for Cheney anyway.
The ultimate decision regarding Cheney’s fate was made by a Kaiser ethicist/administrator who, after interviewing Cheney, concluded that she was competent enough for an assisted death. [Oregonian, 10/17/99. See also Update, 10-12/99]
But information about one such death inadvertently did leak out during a workshop, entitled "Assisted Suicide: Counseling Patients/Clients," held on 12/3/99 at Portland Community College. The speaker was elder-law attorney Cynthia Barrett, who identified herself as a friend of Barbara Coombs Lee, Oregon’s foremost PAS activist and co-author of the PAS law.
Barrett was explaining the various details involved in the PAS process when she set aside her notes and discussed a botched suicide case. "The man was at home; there was no doctor there," she said. "He took the prescription. After he took it, he began to have some physical symptoms," Barrett explained. "The symptoms were hard for his wife to handle. Well, she called 911."
The man was whisked to a local hospital and revived. He ended up in a nursing facility and died sometime later. Information about this case would never have been made public had it not been for Catherine Hamilton, a nurse who opposes PAS. She was not only present when Barrett revealed the case, but she tape recorded the entire account.
George Eighmey, the director of the Oregon chapter of the PAS advocacy group Compassion in Dying, was also present at the workshop. He told those present that the man about whom Barrett spoke "wasn’t one of our patients."
Then, during an afternoon break, Eighmey approached Hamilton, telling her that she should not use the information about the botched suicide nor should she give the information to the media. He said that the class was confidential. [Hamilton, "The Oregon Report: What’s Hiding behind the Numbers?" Brainstorm, March 2000, www.brainstormnw.com]
When interviewed later on Portland’s KXL Radio, Eighmey twice denied knowing anything about the case and suggested that possibly "Mrs. Hamilton is hearing things." But when the radio host revealed the existence of the audio tape of both Barrett’s and Eighmey’s comments at the workshop, Eighmey suddenly ended the interview early. [Oregonian, 3/26/00]
Commenting on this case in relation to the OHD
report, editorial columnist David Reinhard observed, "The Health Division knows
nothing [about this case], though through no fault of its own. Why? Because the doctor who
wrote the Measure 16 [PAS law] prescription, the emergency medical technicians and the
hospital reported nothing. Why? Because Measure 16’s reporting requirements are a
sham." [Reinhard, "The pills don’t kill: The cover-up," Oregonian,
3/26/00]
Dutch study makes Oregon look bad
A Dutch study, published in the same NEJM issue as the OHD report, found that clinical problems and complications associated with the PAS dying process occurred so often that, in nearly 20% of the cases, Dutch doctors opted to give the patients a lethal injection to ensure death. (Lethal injections are allowed in the Netherlands, but not in Oregon.)
Complications such as muscle spasm, extreme gasping, and vomiting occurred in 7% of PAS cases, while patients failed to become comatose, awoke from unconsciousness, or lingered much longer than expected in 15% of PAS attempts.
These figures, Dutch researchers wrote, are likely an underestimate of the actual number of serious problems encountered. [Groenewoud et al., "Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands," NEJM, 2/24/00, pp. 551-556. For more on this study, see "The Netherlands" in this Update.]
The Dutch have had almost three decades of experience with both euthanasia and PAS. Their latest study stands in direct contrast to both OHD reports which disclosed no instances of prolonged suffering, seizures, gasping or vomiting. "Those things have not materialized," explained Dr. Katrina Hedberg, who co-authored Oregon’s official reports.
But some in the U.S. are seriously questioning whether that’s true. "It’s a little incredible to think there is not going to be problems," said Ezekiel Emanuel, M.D., a cancer specialist and researcher at the National Institutes of Health in Maryland. "They ask the wrong questions of the wrong people and give us false reassurances," commented Gregory Hamilton, M.D., president of Physicians for Compassionate Care, a group which opposes PAS. [Oregonian, 2/24/00] And according to columnist David Reinhard, PAS advocates "refuse to admit there can be problems with the state’s assisted-suicide regime — victims and their family members be damned." [Oregonian, 3/23/00]
On the OHD’s official "Prescribing-Physician Interview Form," the following question was purportedly asked of all reporting doctors: "Was the patient specifically referred to you regarding PAS by an organization such as Compassion in Dying or the Hemlock Society?" Both organizations were instrumental in getting PAS legalized in Oregon, and the responses to that question would reveal how influential these advocacy groups are in patients’ PAS "choices." Unfortunately, neither the question nor the resulting data were included in either official report.
Number of PAS deaths
Official
Reports: 43
Actual number: unknown
Number who received lethal drugs more than 6 months before death
Official
Reports: 1 (247 days)
Actual number:
unknown
Shortest time victims had been patients of prescribing doctors
Official
Reports: 2 weeks
Actual number:
unknown
PAS requests based on financial concern
Official
Reports: 0
Actual number:
unknown
PAS deaths of depressed patients
Official
Reports: 0
Actual number:
unknown
PAS deaths of patients with dementia
Official
Reports: 0
Actual number:
unknown
Number of patients who had to see 2 or more doctors before finding
one willing to write lethal prescription
Official
Reports: 24
Actual number:
unknown
Number of patients who experienced complications during
PAS
death process
Official
Reports: 0
Actual number:
unknown
Number of doctors who did not comply with PAS law
Official
Reports: 0
Actual number:
unknown
Number of doctors who did not report PAS deaths
Official
Reports: 0
Actual number:
unknown
Time interval between ingesting lethal drugs and death
Official
Reports: 4 minutes to 26 hours
Actual number:
unknown
Sources:
NEJM First Year Report 2/18/99
and NEJM Second Year Report 2/24/00
2 deaths linked to suicide video broadcast
It wasn’t the first time that depressed but otherwise physically healthy people ended their lives with the guidance of euthanasia and assisted suicide advocate
Derek Humphry and his how-to book, Final Exit. But this time, those contemplating suicide didn’t have to take the time to order the book or obtain it from a store or library. This time, all they had to do was turn on the TV.Less than two days after Humphry’s explicit new Final Exit video was aired in its entirety on a public-access cable station in Oahu, Hawaii, the bodies of two suicide victims ended up on slabs at the Honolulu medical examiner’s office.
Suicide-by-asphyxiation cases are not common in Hawaii. In Oahu, only 2 out of the 99 suicides last year were asphyxiation deaths. That’s why Dr. Kanthi von Guenthner, first deputy medical examiner, became suspicious when she saw that the two suicide victims before her used the same plastic bag method touted by Humphry on the same weekend that his video aired. "I don’t think this was coincidence," von Guenthner said.
She felt that the video, which was aired twice at the request of the Hemlock Society’s local chapter, "had some influence on how and why they died." "Once they see the method," she added, "it encourages them to practice it, or if they are contemplating [suicide], it’s an easy way out."
Neither victim was terminally ill. The first was a man in his 60s who became depressed after a failed relationship. The second victim, Bonnie Blair, 48, had a long history of depression. [Honolulu Star-Bulletin, 3/7/00]
While little information has been released on the male victim, Bonnie Blair’s family and friends went public with her story in hopes of alerting the public about Final Exit’s inherent dangers. Her closest loved ones agreed with the medical examiner that, had it not been for the video and other material Blair ordered from the Hemlock Society, she might still be alive. When friends found her body, they also found a tape-recorded message she had left for them. "I don’t want to do this," Blair said. "I have to do this."
According to Blair’s daughter, Laura Deleski, her mother suffered from depression "off and on forever" for over 30 years. When Deleski was 8 years-old, Blair attempted suicide by overdosing on pills, but relatives got her to a hospital before it was too late.
When Blair moved to Hawaii from Minnesota five years ago, she was upbeat and hopeful that her life would improve. A series of events, however, would dash those hopes. First, she was let go from her job as a chiropractic technician, then she lost a condominium and the $50,000 to $60,000 she had given as part of the purchase agreement. Next, she invested $10,000 in a gum and candy vending machine enterprise which failed.
The hardest blow came when she tested positive for tuberculosis. Without a permanent job, she had no health insurance, but in order to qualify for Med-QUEST, a state and federal program for low-income patients, she was told that she had to sell her stocks and pre-pay her rent months in advance. After she did that, Med-QUEST staff said that she still didn’t qualify because she was $22 over the checking account limit.
Then, on March 3, she was turned down for welfare, ironically because all the rent she prepaid hoping to qualify for Med-QUEST disqualified her for welfare benefits. Tragically, the 33-minute Final Exit video aired that very night.
While there’s no absolute proof that Blair watched the video telecast, her friends and family are convinced that it prompted her death. "Seeing it on TV is a very powerful motivator," said close friend Cheri Hickman, a school teacher. "It’s very, very possible that it was the final, unnecessary push." [Honolulu Star-Bulletin, 4/5/00]
When Derek Humphry was contacted by Hawaiian reporters about the two suicides linked to his video, he said, "The death of any person is deeply tragic, but if these people are intent on suicide, and released themselves in a nonviolent way from their troubles, then I can live with that." [Honolulu Star-Bulletin, 3/7/00]
In a subsequent press release, Humphry stated that those who are not terminally ill, but are suffering from mental illness, should be able to end their lives. "[P]eople who find their mental torment unbearable have the right to leave," he wrote. "Some forms of mental illness are incurable and much more painful than terminal illness." [ERGO!, Press Release, 3/6/00]
Prior to the video’s airing in Hawaii, it was premiered on another public-access TV station in Eugene, Oregon, near Humphry’s home. When news of the scheduled Oahu broadcasts generated criticism in Hawaii, Humphry was quick to point out that Eugene police and a local crisis hot-line found no immediate increase in the number of suicide attempts after his video aired there. [Honolulu Advertiser, 2/14/00]
This no-increase-in-suicide-rate argument was also used by Humphry and the Hemlock Society after the book version of Final Exit, published in 1991, began to be suspected as a contributing factor in a number of suicides across the country. Soon professional journals started running studies and case reports on suicides linked by method or other evidence to Humphry’s book.
One such study, in the American Journal of Psychiatry [December 1994], found that, while the overall number of suicides did not increase between 1990 and 1991, the number of suicides using the two methods (poison and plastic bag) advocated in Final Exit, did increase. In fact, suicides using plastic bags jumped 30.8% after the book was published, and poisonings using Humphry-recommended drugs increased 5.4%.
Another study, published in the New England Journal of Medicine [November 1993], stated that Final Exit was found at the scene of 9 of the 33 asphyxiation suicides in New York City during the year after its publication, and was present at the scene of 2 of the 66 poisonings in which drugs recommended in the book were used. The researchers concluded, "In sum, at least 15 of the 144 people who committed suicide by asphyxiation or poisoning had probably been exposed to the book." Most of those were not terminally ill. Researchers also stated that their suicide figures were likely an "underestimation of the number of people in New York City who consulted Final Exit before they committed suicide."
Senate Judiciary Passes PRPA
On April 25, the U.S. Senate Judiciary Committee passed the much debated Pain Relief Promotion Act (PRPA) by a vote of 10 to 8. The measure, approved by the House last year, would increase funding and educational programs to improve pain management, and would amend the federal Controlled Substances Act to establish aggressive pain treatment as a "legitimate medical purpose" while prohibiting the use of controlled substances for assisted suicide and euthanasia.
The Senate version was amended slightly by Judiciary Committee Chairman Sen. Orrin Hatch (R-Utah) to accommodate concerns expressed by the American Medical Association. This new version maintains state authority over medical practice and establishes the "clear and convincing evidence" standard in cases where a doctor is thought to have used controlled substances for assisted suicide.
As yet, no date has been set for the full Senate vote. [AP, 4/27/00]
Oregon’s cause for shame
by N. Gregory Hamilton
Oregon's claim of "advanced" care for the elderly and seriously ill recently proved a cause for shame in the face of its promoting assisted suicide. When asked to speak, along with the prime minister of
Poland and its minister of the family, at an international conference in Warsaw honoring the elderly, I realized how far my beloved state has fallen. This is the gist of what I said:I am honored to be here in Poland, this great country, which, through its sacrifice, has restored hope throughout the world. Your country has arisen once again to independence only 10 short years ago. Your country is reborn. It is young again.
When my country was still young, over 200 years ago, we believed what our Declaration of Independence so nobly proclaimed: "We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness." But I am sorely grieved, that in my state, which I love, in a country I love, that these truths are no longer honored.
At least one class of people is no longer equal. Their unalienable right to life is no longer recognized. Aged and seriously ill people, stigmatized by the label "terminally ill," can now be put to death through assisted suicide. They are no longer afforded the same protections against discouragement and despair everyone else shares. They can now be handed a lethal overdose instead of the help they deserve.
Your elderly, being honored here today, these brave men and women who survived the Nazi occupation with its policies of euthanasia and extermination, who never surrendered to the enemy, who lived through and eventually cast off Soviet communism, not only for themselves, but for the whole world, these men and women deserve love and respect and help — not poison pills.
Let me tell you some of the things that have happened in my state since assisted suicide was legalized.
Once assisted suicide was accepted, it became impossible to prosecute virtually any killing in the medical setting. For example, the Oregon medical board determined a Corvallis doctor ordered a lethal injection for a woman who did not even request it. Such an action is illegal, even in Oregon. Nevertheless, the district attorney declined to prosecute, because he did not think he could get a conviction in a state that voted to allow assisted suicide.
The people of Oregon were told government reports would function as a safeguard against abuses. Yet, the Oregon Health Division report of the first 15 cases of assisted suicide based its reassuring claims on lack of information, not on clear data. The report even claimed depression was not a problem in the first 15 cases when the medical literature documents that the first publicly reported assisted suicide case had been diagnosed as depressed.
Elderly and ailing patients need good care. They need their physical concerns addressed, including treatment of any pain or depression. They need practical help with day-to-day needs, such as food and shelter. They need people around them who value and respect them and who want them to live, not to commit suicide. They need their spiritual issues taken seriously and addressed.
Places such as Oregon, which no longer believe what America declared at its birth, places like Oregon, which have fallen into the despair of no longer valuing the lives of the ill and the elderly, places like Oregon have much more to learn from than to teach your country, a country which has been reborn and is once again young. The elderly and the ill deserve our love and our help — not poison pills.
N. Gregory Hamilton, M.D., is a psychiatrist and the president of Physicians for Compassionate Care in Portland, Oregon. He has been an vocal opponent of Oregon’s permissive assisted suicide law. Dr. Hamilton’s article is reprinted, with permission, from the Oregonian, 1/31/2000.
State Legislative Digest Arizona: In 1999, Arizonans for Death with Dignity, a chapter of the Hemlock Society, managed to find a legislator willing to sponsor the Arizona Aid in Dying Bill (HB 2167), which was closely patterned after Oregon’s assisted suicide law. The measure, however, met with a quick death without ever being heard in any committee. Acknowledging the lack of legislative support, the state’s assisted suicide advocates are changing strategy and tentatively making plans for an initiative drive in 2002, depending on the outcome of Maine’s assisted suicide initiative vote in November 2000. [Arizonans for Death with Dignity web site: www.azstarnet.com/%7Edavidbe/hemlock/]
California: The California Death with Dignity Act (AB 1592), a bill that would have made assisted suicide a legal "medical treatment" in California, officially expired on January 31, 2000. Due in large part to strong opposition by a broad-based, grass roots coalition — consisting of advocates for the poor, migrant worker advocates, medical and hospice professionals, disability rights activists, ethnic minority groups, pro-life supporters, and religious organizations — Assemblywoman Dion Aroner (D-Berkeley), the measure’s sponsor, opted to let the bill die quietly rather than have it formally defeated in a full Assembly floor vote.
The bill, a clone of the Oregon assisted-suicide law, had previously passed both the Assembly Judiciary and Appropriations Committees, but not without strong-arm political maneuvering on the part of Aroner and a few like-minded legislative friends. It was the first time that an assisted suicide or euthanasia measure had been passed by any committee in the California Legislature. But given the opposing coalition, Aroner was not able to garner the votes she needed by the deadline to get the measure passed by the full Assembly.
Commenting on the bill’s demise, IAETF Executive Director Rita Marker said, "This shows the effectiveness of building coalitions to oppose the assisted suicide agenda." "The coalition members in California were people who may have disagreed about other issues, but who came together in the common understanding that assisted suicide would be disastrous to society’s most vulnerable members," she added.
Aroner, a Hemlock Society member, has indicated that she intends to keep the assisted suicide "dialogue" before the public. She convinced the Assembly speaker to resurrect the Select Committee on Palliative Care and name her chairperson, stating in a letter that, by holding public hearings, she hopes to "continue the increasingly important public dialogue surrounding the broad range of end-of-life care issues including physician assisted dying." She also plans to introduce another assisted suicide bill during the next legislative session. [Capitol Journal, 2/7/00]
The second bill, HB 1668, would require the State Board of Healing Arts "to automatically revoke the license of a physician who is found guilty of or who has entered a plea of guilty or nolo contendere for assisting in a suicide in any jurisdiction of the United States or if there is convincing evidence that the physician has assisted in a suicide in any jurisdiction." The measure would also make "knowingly causing another person to commit or attempt to commit suicide" a class B felony and would establish "a cause of action for injunctive relief" for civil damages and attorneys‘ fees "against a person who assists or attempts to assist another person to commit or attempt suicide." [HB 1668, Bill Summary]
The latest version, SB 44, was heard in the Senate Judiciary Committee on March 8, 1999 and was subsequently "rerereferred" back to committee on April 1, 1999. The measure resurfaced in January of this year after a majority Judiciary Committee report recommended passage of an amended version of the bill. However, on February 3, after hearing testimony on both sides of the issue, the Senate rejected the proposed amendment by a vote of 22 to 2, and defeated SB 44 by a vote of 19 to 5. [Senate Journal, No. 2. pp. 53-55; Concord Monitor, 2/4/00; Foster‘s Daily Democrat, 1/14/00]
World Focus
Australia
Nitschke gets OK for death clinics in
Tasmania
Euthanasia advocate Dr. Philip Nitschke has been granted
permission to establish his death clinics in the state of Tasmania. According to Nitschke,
the registration process went smoothly, unlike his experience elsewhere in Australia.
Nitschke claims that he already has eight terminally-ill Tasmanian patients scheduled for
his euthanasia "advisory" clinics on May 1, 2, and 3. He plans to see most in
their homes, but is also looking for a "sympathetic location" where patients can
come for his death counseling.
Nationally, 105 people attended the clinics in 1999,
but Nitschke has not tallied up the resultant body count. He has said that the average age
of his attendees nationwide was 69 and that approximately 70% were women. He added that
half were terminally ill, usually with cancer, but the rest were simply elderly people
fearful of becoming terminally ill in the future. [Melbourne Herald-Sun, 2/16/00:12]
Suicides among Australian youth increasing
Official suicide figures released by the Australian Bureau of
Statistics reveal that Australians are committing suicide at an increasingly younger age.
According to the most recent data, it was the 15 to 24 age group which showed the most
dramatic suicide rate increase, accounting for 27% of all male deaths. The highest suicide
rate in 1998 was among those aged 25 to 44, while the rates for those 65 and older
declined. The suicide rate in Australia’s rural areas was almost 50% higher than in
urban areas. Most interesting was the finding that the rural Northern Territory —
where euthanasia was temporarily legal between July 1996 and March 1997 — had the
highest suicide rate in the country. [Reuters, 3/29/00]
Belgium
Belgium considers euthanasia proposal
Belgian Upper House of Parliament is considering a proposal initiated by an alliance of senators to legalize euthanasia. The proposal would establish guidelines under which doctors would be allowed to euthanize patients. The guidelines are similar to those established in the Netherlands, with the added provision that doctors can honor written euthanasia requests in the event that patients loose their mental competence or consciousness permanently. The written request would have had to be signed and witnessed within 5 years prior to the signer’s euthanasia death.
While Belgium lawmakers have been debating the euthanasia issue since 1996, the government’s bioethics advisory committee has remained divided on the issue. Dr. Marc Moens, head of the Belgian Association of Doctors Syndicates, the largest medical group in the country with members comprising two-thirds of Belgium’s 40,000 physicians, is strongly opposed to changing the current law to allow euthanasia. He has argued that legalizing euthanasia would not prevent abuses and would make "the exception the rule." [British Medical Journal, 1/15/00:137]
Ethics committee wants euthanasia "tolerated"France’s National Ethics Committee has issued a report recommending that euthanasia be allowed under certain conditions, such as when pain is unremitting, when all treatment and therapy have failed, or when there is unanimous agreement that the patient’s circumstances are intolerable. The report, which took three years to complete, does not advocate that euthanasia be legalized, just tolerated — as has been the case in the Netherlands. "A type of euthanasia exception could be imagined," the report said, pointing to a possible loophole in the law that could be used to protect doctors from prosecution.
The government-sponsored ethics committee is only a consulting group, however, the majority of its recommendations are adopted by French lawmakers. According to BBC news, this committee has, in the past, "made recommendations on sensitive topics such as the sterilization of the mentally handicapped." The committee justified its euthanasia stance by stating that mercy killing is currently being practiced clandestinely in an "unequal and anarchic" way. The report now goes to parliament for debate. [BBC News, 3/3/00; Reuters, 3/3/00] ®
Great Britain
Elder abuse and involuntary euthanasia reported
Recent news and investigative reports have revealed that the care of the elderly in the U.K.’s National Health Service (NHS) has become "a national disgrace," prompting the heads of three Royal Medical Colleges and the British Geriatrics Society to call for more NHS funding and treatment equity throughout the health system. [BBC, 3/31/00; Edinburgh Evening News, 3/31/00]
A six-week undercover investigation of two London hospitals, conducted by the Sunday London Times, concluded, "Shocking inhumanity, negligence and criminality are everyday features of the National Health Service."
Reported cases of abuse include an elderly male patient who fell in the presence of a physiotherapist, gashing his head and dislocating his knee. Bleeding profusely from the head and complaining about acute knee pain, the man was left suffering in a wheelchair — abandoned by a senior doctor who dismissed the knee pain and then attended a meeting instead of stitching up the man’s 4-inch head wound. The patient sat over four hours before his knee was x-rayed and found to be dislocated.
Other instances involved nurses who cruelly mocked elderly patients when they lost control of bodily functions, in some cases leaving patients to sit in their own excrement. One male patient "had fluid seeping from open sores on his lower leg," and "his toenails were gnarled and overgrown and clearly had not been clipped in months." A female patient said that nurses often abused her. "I’ve been here for weeks now and the treatment is terrible. But nobody knows what goes on here, and I doubt people ever will. Who is there to hear us?" [Sunday London Times, 3/12/00]
An independent official report on a hospital in Carlisle, published in March, uncovered similar abuses of the elderly and described "how patients had been beaten, tied to lavatories and force-fed." [Sunday London Times, 3/19/00; Daily Telegraph, 3/18/00]
While serious allegations — that elderly patients were being denied appropriate treatment and food and fluids to free up medical facility beds — surfaced in late 1999 (see following story), new horror stories, including instances of involuntary euthanasia, were recently revealed by a junior NHS doctor.
In another hospital, Pal was ordered to give an elderly pneumonia patient an injection of diamorphine, a drug used to treat heart conditions and pain, but in higher doses can also cause death by suppressing respiration. Pal was sure that the dosage ordered would be fatal so she injected the drug into the patient’s mattress instead. The next day, when a doctor noticed that the elderly patient was still alive, he asked Pal, "Oh, she is still alive — didn’t you start her on diamorphine?" Later the woman recovered fully and left the hospital. "I have lost faith in medicine," said Pal. "There is a code of silence and it’s the hardest thing to stand up and say something." [Sunday London Times, 4/2/00]
Freeing up beds by denying care for those over 65 is common within the NHS. One early-stage cancer patient found out by accident that a doctor she had never met wrote on her chart, "In view of the underlying diagnosis [cancer], in the event of cardiac arrest or stroke, resuscitation would be inappropriate." "I could have been left to die without even having a choice about it," the 67-year-old woman said. "This doctor was playing with my life." [BBC, 4/13/00, The Scotsman, 4/13/00, Daily Telegraph, 4/13/00]
The Medical Treatment (Prevention of Euthanasia) Bill (MTPEB), introduced late last year by MP Ann Winterton, has been blocked in Parliament. The bill was intended to "halt the slide towards the acceptance and practice of euthanasia by making it clear to doctors that they cannot intentionally bring about the death of their patients by action or omission." [Daily Telegraph, 1/27/00] It was a direct response to guidelines issued last year by the British Medical Association (BMA) giving doctors ultimate authority — even over family members and designated health care decision-makers — regarding the withholding and withdrawal of medical treatment, including food and fluids.
According to the BMA, "The main focus of the new [guidelines] is decisions about patients who are likely to live for weeks, months, or possibly years, if treatment is provided but who, without treatment, will or may die earlier. It covers patients of all ages." "Decisions about whether to provide, withhold or withdraw treatment," the BMA held, "are the responsibility of the treating doctor with the advice of the rest of the health care team and with reference to the courts in particularly contentious, difficult or disputed cases." [BMA Press Release, 6/23/99. See IAETF Update, 4-6/99:9.]
The MTPEB was short and focused, simply stating, "It shall be unlawful for any person responsible for the care of a patient to withdraw or withhold from the patient medical treatment or sustenance if his purpose or one of his purposes in doing so is to hasten or otherwise cause the death of the patient." But the BMA forcefully opposed the measure, and sent a letter to all members of Parliament (MPs) arguing that the bill would "confuse an already complex process, result in poor quality patient care, and remove patient autonomy." [Letter from the Chairman of BMA Council to MPs, 1/21/00; BMA Press Release, 1/24/00]
Despite the BMA’s lobbying efforts and other opposition during the MTPEB’s First Reading in the House of Commons, the measure was given a Second Reading on 1/28/00 by a vote of 113 to 2. However, on 4/14/00 during the Commons debate on the bill, opposition from medical groups, the public health minister, and MPs became very vocal, and the allotted debate time for the measure ran out. The bill now joins a long list of "backbench" bills for future debate, and has almost no chance of becoming law. [BBC, 4/14/00]
According to Dr. Michael Wilks, chairman of the BMA’s Medical Ethics Committee, "That may appear to be a simple reaffirmation of existing law and policy, but behind the decision lies two days of intense and thorough debate." "The consensus statement," he explained, "is remarkable for the fact that delegates with fundamentally and diametrically opposing views on end-of-life issues were able to agree on a position with which they all feel comfortable."
Agreement was reached on numerous aspects of PAS, including practical concerns such as: drugs not normally used would have to be distributed and there would be a danger disseminating these lethal drugs into the community; to practice PAS effectively, doctors would likely have to "administer the drugs parenterally" instead of relying on the patient to self-administer them orally; and it would be considerably difficult to establish "consistent criteria" for deciding which patients would qualify for PAS. [BMA Press Release, 3/4/00; BMJ, 3/11/00 & 4/1/00]
The Netherlands
Clinical problems and complications associated with euthanasia and PAS
Deaths caused by euthanasia and physician-assisted suicide (PAS) often are not the humane, dignified, easy, or painless deaths that advocates promise. In fact, according to a new Dutch study published in the New England Journal of Medicine (NEJM), technical problems, complications, and problems with death completion occur in 16% of all euthanasia and PAS cases. [Groenewoud, et al., "Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands," NEJM, 2/24/00, p. 551]
Researchers found that "problems were more frequent in cases of assisted suicide than in cases of euthanasia." [p. 551] Of the 114 PAS cases studied, 10% experienced technical problems (i.e., difficulty administering the lethal drugs orally or finding a vein), 7% encountered serious complications (i.e., spasms, cyanosis, nausea, vomiting ), and 15% had "problems with completion" (i.e., patient did not die within the expected time-frame, patient awoke from coma or never became comatose). Of the 535 euthanasia cases studied, 5% had technical problems, 3% experienced complications, and 5% had death completion problems. [Table 3, p 554] The time interval between the administration of the first drug and the doctors’ assessment of the time of death ranged from 5 minutes to 7 days for all the euthanasia cases and from 1 minute to 14 days for all the PAS deaths. [Table 5, p. 555]
In PAS cases problems arose so often that doctors felt compelled to take over in 18% of the cases, giving the patients lethal injections (euthanasia) to ensure their deaths. [p. 554] In 3% of the cases, someone other than a doctor or nurse administered the fatal drugs, and in 4% of the PAS cases, the administering person was "unknown." Among the euthanasia deaths, the doctor gave the lethal injection in 91% of the cases, nurses in 4%, a person other than the doctor or nurse in 1%, and an "unknown" person in 4% of the euthanasia cases. [Table 2, p. 553]
The Dutch researchers acknowledge that "unexpected events can be traumatic" for all those involved in a patient’s hastened death. [p. 556] They also admit that their study may be limited by the fact that "the information was provided by the responsible physician in each case, who may have underestimated the number or seriousness of problems." [p. 555, emphasis added]
According to the British medical journal The Lancet, the coordinator for the Dutch Medical Association’s committee on euthanasia, Eric van Wijlick, commented on the new Dutch study (see above story), stating that he knew there were clinical problems with PAS and euthanasia, but that the Medical Association does not have a policy on developing solutions to those problems. However, he said the Dutch government is currently spending the equivalent of $3 million (U.S.) to train general practitioners to be "euthanasia consultants," specialists who will be randomly assigned out of a central office to give second opinions regarding patients being considered for euthanasia and PAS deaths. Van Wijlick speculated that these "consultants" could likely play a role in improving the "quality of care." [The Lancet, 3/4/00:811]
The decision to forego "life-prolonging treatment" is an increasingly frequent choice made in the Netherlands, according to a nationwide study. The treatments most often withheld or withdrawn are "artificial nutrition and hydration" and antibiotics. Of the patients for whom foregoing treatment was the most important end-of-life decision, 67% were not fully competent. Of those, information about the patient’s previous wishes was available in only 13% of cases. Doctors often did not discuss the termination of treatment with patients or their families. According to researchers, "in exceptional cases, physicians in our study failed to discuss the nontreatment decision even with competent patients because they thought the decision was clearly the best for the patient." [Groenewoud et al., "A Nationwide Study of Decisions to Forego Life-Prolonging Treatment in Dutch Medical Practice, "Archives of Internal Medicine, 2/14/00, 357-363]
The Scottish Parliament has passed the hotly debated "Adults with Incapacity Bill," which supporters claim will guarantee the rights of people who cannot make decisions for themselves because of illness, accident, or cognitive disability. But opponents argue that the measure allows non-therapeutic research and experimentation to be done on incompetent adult patients who are unable to give informed consent. Deputy Minister for Health and Community Care Iain Gray, who backs the bill, explained, "I want to reaffirm our commitment to widening the conditions which will allow research on an incapable adult. Research will be permitted if it could benefit other future sufferers or incapacitating conditions." [Scottish Executive, Press Release, 2/29/00]
Opponents also point out that the bill will permit "backdoor euthanasia" by allowing "welfare attorneys" to be appointed to make health care decisions, including the termination of food and fluids, for incompetent patients. To counter that argument in the minds of Parliament members, Gray amended the bill to stipulate that doctors would have the final say over treatment decisions. Relatives could object, but the objections could be overruled by a second consulting doctor. [BBC, 2/29/00 & 3/29/00; The Scotsman, 3/30/00]
Comment: Health care in Scotland is provided by the NHS. Given the current NHS scandal regarding doctors denying care or hastening death to free up beds (see p. 9), it would appear that Gray’s amendment is hardly protective.
Research in Review
Understanding burdens of terminal illness reduces depression in patients and caregivers
A study published in the Annals of Internal Medicine, found that "substantial care needs are a key mechanism that generate economic and psychosocial burdens on terminally ill patients, their families, and their caregivers." Financial and other burdens, added to the emotional experience of dealing with a terminal illness, can cause patients to have suicidal thoughts and caregivers to be depressed. According to researchers, the study data indicate a definite link between patients’ reports of substantial care needs — transportation, nursing care, homemaking, and personal care — and the patients’ consideration of euthanasia or physician-assisted suicide as a way out.
Researchers studied 988 terminally ill patients and 893 caregivers from 6 randomly selected cities across the country. Financial worries and burdens had a significant effect on the stress levels of both patient and caregivers. The study found that 28% of patients with the highest care needs spend 10% of their household income on health care costs other than health insurance, and over 16% of those with high care needs said that they or a member of their family had to sell assets, get a loan or a mortgage, or find additional work to pay the care costs.
Researchers emphasized, however, that their data show a way some of the burdens on caregivers can be lessened without incurring additional costs. Empathic physicians willing to listen to both patient and caregivers can significantly reduce the burdens and the depression often felt by caregivers. "Training physicians to listen," researchers wrote, "and increasing coverage of additional home care services — especially unskilled assistance — without increasing patients’ and families’ expenses could effectively relieve economic and other burdens." [Emanuel et al., "Understanding Economic and Other Burdens of Terminal Illness: The Experience of Patients and Their Caregivers," Annals of Internal Medicine, 3/21/00, 451-459]
"Doctors who really listen to patients and caregivers and spend time understanding, that lessens the burdens on caregivers," explained lead researcher Dr. Ezekiel Emanuel from the National Institutes of Health in Bethesda, Maryland. "They feel heard. It’s a key element to feeling supported." Emanuel suggested that doctors be taught listening and empathy skills during medical school, internships, and residency programs. [AP, 3/21/00] ®
A study at the University of Chicago of 365 physicians and 504 hospice outpatients revealed that only 20% of the doctors’ prognoses on patients’ life expectancy were accurate. Most predicted survival times (67%) were overly optimistic; 17% were found to be overly pessimistic. More experienced doctors made fewer prognostication errors, but the more a doctor knew the patient, the more likely it was that the prognosis would be inaccurate.
The study’s authors point out that "undue optimism about survival prospects may contribute to late referral for hospice care, with negative implications for patients." In fact, the study found that, while doctors say that terminally ill patients should have hospice care at least three months before death, patients usually get such care for a month or less. "The fact that doctors have unduly optimistic ideals about how long patients have to live may partly explain this discrepancy," researchers concluded. [Christakis and Lamont, "Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study," British Medical Journal, 2/19/00,469-472]
An article on this study, published in the Oregonian, pointed out another significant implication. Since doctors’ prognoses are inaccurate 80% of the time, both overly optimistic and overly pessimistic, reporter Joe Rojas-Burke concluded, "The [study’s] results imply that patients in Oregon who choose doctor-assisted suicide may not be getting an accurate opinion about when they’re eligible for a lethal prescription under Oregon’s Death with Dignity Act." [ Rojas-Burke, "A Matter of life and guess," Oregonian, 2/17/00]
News Notes Robert Wendland’s fate still rests in the hand of the California judiciary. Robert’s wife, Rose, has been waging a 4-year legal battle to have Robert, 48, starved and dehydrated to death, claiming that he wouldn‘t want to live in his current condition. Robert, who is neither terminally ill nor in a vegetative state, is physically and cognitively disabled as a result of a truck accident almost 7 years ago. Before his rehab therapy was stopped by his wife, Robert could maneuver his wheelchair around the hospital and could write the letter "R" and other letters in his name. He could even press the appropriate buttons to accurately answer "yes" or "no" to questions. He worked hard and cooperated with his therapists. (See Update, 11-12/97, pp. 10-11.]
But on 2/24/00, California’s 3rd District Court of Appeals, in a rather convoluted ruling, reversed a lower court decision barring Rose, Robert’s conservator, from ordering the withholding of his tube-provided nutrition and hydration According to the justices, food and fluids through a tube is considered "medical treatment," and, in California, a conservator has the "exclusive authority" to order such treatment stopped, even from a conservatee who lacks "capacity to make his own decision, but who is not terminally ill or [in a persistent vegetative state]."
The justices also said that the lower court erred by requiring Rose to prove by "clear and convincing evidence" that Robert would want to die. Instead, they ruled, that Rose should only be required to provide "clear and convincing evidence" that she is acting in good faith and on sound medical advice. [Wendland v. Wendland, C0299439, Court of Appeal of California, Third Appellat District, 78 Cal. App. 4th 517]
The justices remanded the case back to the lower court to give Robert’s mother — who, despite poor health, has been fighting for Robert’s life — a chance to prove that Rose is neither acting in good faith nor in Robert’s best interest. Meanwhile, Janie Hickok Siess, the attorney for Robert’s mother, has appealed the 3rd District Court’s ruling to the California Supreme Court. [Cal Law, 2/25/00; Stockton Record, 2/25/00]
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"This is really outrageous," said Mayer Morgenroth, Kevorkian’s lawyer. "I am considering filing a lawsuit on the grounds of cruel and unusual punishment." According to a Department of Corrections spokesperson, "There are no plans to transfer him anywhere else." Kevorkian, who claims to have "assisted" 130 disabled folks to an early death, is currently serving a 10 to 25 year sentence for the videotaped euthanasia death of Thomas Youk. [Oakland Press, 3/22/00;3/19/00]
But life hasn’t been all bad for the man called Dr. Death. In April, he received a $50,000 humanitarian award from the Gleitsman Foundation. Members of the disability rights group Not Dead Yet protested the award. "I know of no other humanitarian award that’s been awarded to a serial killer like Jack Kevorkian," said NDY member Tom Cagle. [AP, 4//10/00] ®
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Dr. Georges Reding, Jack Kevorkian’s former apprentice, is still hiding from New Mexican authorities. He’s been a fugitive since 9/3/99 when he failed to appear for his arraignment on charges of first-degree murder, drug trafficking, evidence tampering, and practicing medicine without a license — all stemming from the 8/30/98 death of New Mexico resident Donna Brennan, a 54 year-old multiple sclerosis patient. Evidence places Reding, a Michigan psychiatrist, at Brennan’s home just prior to her death. (See Update, 7-9/99:4.)
Late last year, Brennan’s family filed wrongful death civil suit against Reding, and a judge found him liable for compensatory and punitive damages for his involvement in Brennan’s death. (See Update, 10-12/99:9.)
Now Brennan’s family has filed another suit, this one aimed at Brennan’s neighbors, Bernadette and Ruben Griego. According to the suit, the Griegos "encouraged Donna J. Brennan by acts and words to commit suicide" in order to acquire her assets. The family contends that the Griegos got Brennan to sign a "payable on death" account at a local bank so they could collect about $35,000. The Griegos’ lawyer said that it was Brennan’s decision to leave her assets to her neighbors. "That was Donna’s decision. It was never a quid pro quo," he said. [Albuquerque Journal, 3/30/00]