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Taking ‘Death with Dignity’ lessons from Oregon

Former Oregon Governor Barbara Roberts speaking at an Emily's List conference in 2006.

Former Oregon Governor Barbara Roberts speaking at an Emily's List conference in 2006. (Wikipedia contributor Andie Petkus)

They served together as progressive Democratic governors and now, as retired senior statesmen, Booth Gardner and Barbara Roberts have a common cause in advancing a “Death with Dignity” law for Washington that is modeled on the Oregon law created by citizen initiative while Roberts was governor. Few people are more familiar with the Oregon experience than Roberts, governor from 1991 to 1995.

Roberts notes that she watched the evolution of Oregon’s law “every step of the way.” She was a state legislator when her husband, State Sen. Frank Roberts, introduced the first physician-assisted suicide bills in the Oregon Legislature, all of which failed. She was governor when her husband died of cancer, during the initiative campaign to put the measure on the ballot. She spoke for it in 1994 and 1997. Later she took training for volunteers dealing with end-of-life issues, wrote a book on dying and grieving, and stood by her best friend when she obtained prescriptions to end her life (but ultimately decided against using them). Roberts has testified before legislatures in Vermont and California.

The public in Oregon, and many other states, supports physician-assisted suicide, Roberts is convinced. Because the subject is “frightening to legislators,” she adds, a citizen initiative like Oregon’s and like I-1000 is generally the only way to pass the law. Roberts spoke with Former Washington Governor Booth Gardner when he began his initiative efforts, and will appear in advertising for the initiative.

I-1000, the Washington “Death with Dignity” initiative, like the Oregon law, applies only to adult patients who are determined by two physicians to be terminally ill, facing death within six months, and mentally capable of making a decision to end their lives. They may request a physician to prescribe a life-ending overdose, usually either secobarbital or pentobarbital, which the patient would self-administer. Applications must be both written and oral, with witnesses.

Oregon has had 11 years’ experience with the type of law that Washington voters decide this fall. The law has survived a ballot challenge, a U.S. Supreme Court test, and a full-court press by the Bush Administration. It maintains strong support in the state, and the experience has brought several unexpected results and debunked most of the fears raised by opponents.

Opponents feared the law would be “a burden on the poor,” who would be pressured to die rather than run up large medical bills. Statistics collected by the Oregon Public Health Division indicate a population of patients not likely to fit that description. A full 99 percent had either Medicare and private insurance or both, 50 percent had college or graduate degrees, and 66 percent were married or widowed. Patient populations were overwhelmingly (97.4 percent) white. A private organization, Compassion and Choices of Oregon, goes beyond the state’s statistics, adding that an equal number (42 percent) of patients self-identified as Republican or Democrat, and 89 percent self-identified with a religious faith.

Roberts is well-equipped to rebut fears that the law would target people with disabilities. She is the mother of an autistic son and was a parent-lobbyist for the disabled long before she entered politics. “Let me state emphatically, I would never support a law that was harmful to individuals with disabilities. This proposed law is not a slippery slope that threatens those with disabilities of any kind,” Roberts states in a recent Post-Intelligencer op-ed.

No previously disabled person has used the Oregon law.

Some opponents predicted a rash of applicants from outside Oregon, but that has not occurred. In fact, the use of the law has been rare. The 341 deaths were less than three thousandths of one percent of Oregon deaths from the same diseases during the same period. Doctors had written 541 prescriptions for patients during this period, so less than two-thirds of patients actually used the life-ending drugs. It is unknown how many other Oregonians explored the assisted-suicide option, but Compassion and Choices, a leading organization in this area, reports counseling 160 people during 2007, of which only 31 used the assisted-suicide option. Most others were referred to hospice care or to religious or spiritual counselors. Volunteers reported talking 11 people out of committing violent suicide. “There is no tidal wave of patients moving to Oregon to die, and there is no evidence of a slippery slope toward involuntary euthanasia there, as opponents once feared,” the American Medical Association newsletter reported in its May 12 issue. Both doctors and organizations working with patients are required to recommend that patients notify family members; the state reports that 94.7 percent of patients did notify family.

Medical objections remain, based primarily on the method of death — ingesting a large overdose of secobarbital or pentobarbital — and the lack of mandatory psychiatric examination. Doctors are required to consider the mental health status of applicants, but refer them for counseling only if appropriate (I-1000 has the same requirement). Oregon reported that 5.7 percent of patients had some complications, all but one with regurgitation of the pills. The latter case involved a man who awakened 65 hours after taking the pills; he died from his lung cancer two weeks later. Oregon does not allow — nor would I-1000 — use of lethal injections by a physician.

The Oregon initiative passed by 627,980 to 596,018 in 1994, after a low-key campaign in which both the Oregon Medical Association and Oregon Health Care Association held neutral views. After a federal judge enjoined the law, it remained in limbo until October 1997, when the Ninth Circuit Court of Appeals lifted the injunction and put the law into effect.

While the legal battle was played out, the Oregon Legislature sent the law back to the voters in November. Voting a few days after the Ninth Circuit ruling, Oregonians expanded their margin of approval to 666,275 to 445,830, although the medical and health-care associations now weighed in against the law.

As the law marks its eleventh year next month, most of the “what if” reasons for opposing it have been disproved. Opposition remains, of course, from those with moral, ethical, or religious opposition to physician-assisted suicide under any circumstances.

Medical associations remain one of the major opponents to Oregon-style laws, although a 2005 national survey by an independent research firm, reported in the American Medical Association’s newsletter, showed 59 percent of physicians surveyed said yes when asked, “Do you think physicians should be given the right to dispense prescriptions to patients to end their life?” Forty-one percent said no. When asked who should decide whether physician-assisted suicide is a “legitimate medical purpose,” 25 percent said the state should decide, and 21 percent said it should be the federal government. But 54 percent of doctors said neither level of government should be the one making the decision.

The official stance of medical associations in both Oregon and Washington is opposition to physician-assisted suicide. The AMA “strongly opposes any bill to legalize physician-assisted suicide” because the practice is “fundamentally inconsistent with the physician’s role as healer.” Physicians’ concerns brought the only real changes in the Oregon law when it was redrafted for Washington. The redraft provides additional guards to protect health care providers from being required by an employer to participate in an assisted-death act, and it allows a doctor or health care provider to prohibit use of their premises for such an act. Other added safeguards deal with writing of prescriptions and state reporting.

The Oregon route to assisted suicide began in 1972, before an astounded audience of Republicans, when Gov. Tom McCall asked the assembly to consider what he called “death with dignity.” McCall, a masterful wordsmith, urged “death with dignity” as “opposed to death as a vegetable.” Asking, “Does man get into the area of playing God when he contemplates death with dignity,” the governor asked, “or is he already playing God by administering wonder medicines that have helped double life expectancy in the past 100 years?” Seven months after his speech, McCall was diagnosed with prostate cancer, which took his life in 1983. It is likely that McCall would have supported, and perhaps used, the 1994 Oregon law; his widow, Audrey, served on the advisory board of Compassion and Choices of Oregon, prior to her death in 2007.

If McCall opened the Oregon debate, two successors also played a role in its passage and support. Roberts supported the law in 1994 and 1997 and has served on the Compassion and Choices advisory board and written extensively on end-of-life issues. Her successor, John Kitzhaber (1995-2003), is a physician, and wrote in 1997 in support of the Oregon law, “As a physician, I can tell you there is a clear difference between prolonging someone’s life and prolonging their death. One of the downsides of modern medicine is that often it prolongs people’s deaths, which I am not sure is humane and I am not sure is ethical.”

The extensive use of hospice care and the expansion of other forms of palliative care has been a side effect of the Oregon law, acknowledged by the American Medical Association. The AMA newsletter states:

Since Medicare began reimbursing hospice services in 1982, the number of patients choosing this end-of-life care option has grown steadily. One in three Americans now dies under the care of a hospice program, and the number of programs has grown almost 50 percent since 1997. In Oregon, overall hospice use has jumped 84 percent since the use of the Death with Dignity Act. Nearly six in 10 dying Medicare-age patients there received hospice care in 2005, the most recent year for which data are available. Oregon placed ninth among states on hospice utilization in 2005. Though Oregon’s law remains seldom used and unduplicated, its impact on physicians, patients, and the movement to improve end-of-life care cannot be overstated.

The article quotes Dr. Chuck Hoffman, former president of the Oregon Medical Association, describing the law as having “done more good than harm because it forced the end-of-life discussion to come sooner, and we’re more prepared. We can assure the patient that when there’s no hope of being restored to health, they are not going to suffer and will be kept comfortable even if the treatment hastens death. When they understand that, assisted suicide goes way down the list of their concerns.” Hoffman, a Baker City internist, supports the Oregon choices, but refers patients who request assisted suicide procedures.

There have been no major attempts to repeal the Oregon law since the vote of 1997, and Roberts believes that the law is so well written that it will withstand any additional legal challenges. She says politicians in Oregon recognize its popularity. “If a politician in Oregon comes out against Death with Dignity, he or she’s in real trouble.”

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