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Physician-assisted suicide in Oregon: why so few occurrences?

Howard Wineberg

MJA 2001; 174: 353-354

In the first three years that physician-assisted suicide (PAS) has been legal in Oregon, about two persons per month have taken medication to end their life. Most physicians are unwilling to prescribe the lethal medication. Because many terminally ill people are confined to their bed or home, the difficulty of finding a willing physician may have resulted in many abandoning the idea of using PAS. People living a long way from a large urban centre may be severely disadvantaged in their ability to obtain medication to end their lives.

Legal requirements - Oregon - Using PAS - Not using PAS - Conclusion - References - Authors' details
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  Physician-assisted suicide (PAS) has been legal in the state of Oregon, USA, for more than three years. The Oregon Health Division, the agency responsible for monitoring Oregon's Death with Dignity Act, has produced official reports documenting the number and characteristics of Oregonians who have used the provisions in the law to take medication to end their lives in the years 1998-2000.1-3 Only 70 people legally took medication to hasten their death during this period — in this article I examine some of the reasons why.


Legal requirements

Under Oregon's law,4 only Oregon residents who are aged 18 or over and have a terminal illness with a life expectancy of less than six months are eligible to request a prescription for medication to end their life. Patients must self-administer (swallow) the medication — euthanasia (involving a physician's active intervention) is not allowed. The physician's prognosis for the patient must be confirmed by a consulting physician and both physicians must determine that the patient is capable of making his or her own decision and does not have a mental health condition that impairs his or her judgement. The patient must make two oral and one written requests for the medication, and at least 15 days must elapse between the first and the final request. Physicians are not obligated to participate in PAS.


Population and geography of Oregon

Oregon occupies 96 000 square miles and borders the Pacific Ocean. Of the 3.3 million residents of Oregon, 1.4 million live in the Portland Metropolitan Area.5 Many of Oregon's counties are sparsely populated — half of the counties are east of the Cascade Range, yet this area contains only one city of at least 20 000 people.5 Many people living in eastern Oregon are a 5-7-hour drive from Portland or another metropolitan area.


The number of people using PAS

In the first three years of operation of Oregon's law (1998-2000), 70 people legally took medication to end their lives. Although the number increased from 16 in year one to 27 in years two and three, only about two people per month, on average, are using PAS,1 and only 0.07% of Oregonians die of PAS in a year.6 By comparison, around 545 people per month die of cancer in Oregon.7

While the United States and the Netherlands are not directly comparable to one another, it is noteworthy that in the Netherlands about 2.4% of all deaths are from euthanasia and 0.3% from PAS.8 In Oregon, approximately 10% of all requests for PAS result in the person taking the medication to end their life, whereas in the Netherlands about a third of the requests result in death by euthanasia or PAS.9,10 In Australia, despite threats that physicians participating in euthanasia would be legally culpable, in the nine months that euthanasia was legal in the Northern Territory (from July 1996 to March 1997) four people died by this means,11 representing 0.7% of all deaths in the Northern Territory during that time.12

I must emphasise that my focus is on legal PAS in Oregon. Illegal PAS and euthanasia probably still occur, although their extent is unknown.


Reasons for terminally ill people not using PAS

One reason why so few people may have taken medication to end their lives is that an individual must wait at least 15 days after making the initial request to receive medication. This makes it difficult for people to use PAS on a whim. Terminally ill individuals have mentioned that the process one needs to go through to finally receive the medication can be quite burdensome (because of the waiting period, the need to get two physicians to confirm that the patient has a life expectancy of less than six months, and the requirement that the patient must get two people to witness the written request for the lethal medication).9 Approximately 30% of patients requesting a prescription may die before completing the requirements of the law.9

Recent improvements in palliative care in Oregon13 may have allowed some people to die in relative comfort without having to hasten their death. Oregon has one of the highest rates of hospice admission and morphine usage per capita in the United States.14 It is estimated that about 45% of the patients for whom a substantive intervention is made will change their minds about wanting a prescription for a lethal medication.9

Just knowing that they can receive medication to end their life, if desired, is comfort enough for some individuals15 — the Oregon Health Division statistics show that 19 people who eventually died of their underlying illness had had the medication but not used it.1

Some people may be unable to swallow the medication themselves and thus can not use PAS.4 Others may fear that even if they swallow all the medication it may not kill them,16 and thus they do not attempt PAS.

The above factors notwithstanding, I believe the most important reason for the limited use of PAS is that this service is not readily accessible to many Oregonians. Approximately 60% of the patients had to go to more than one physician before finding one who would write the prescription.1 The Oregon Health Division reported that only a fifth of physicians of control patients dying of similar terminal illnesses would have prescribed a lethal medication if asked,2 and, in a study of Oregon physicians, Ganzini et al9 found that only 16% of those asked actually wrote a prescription. The Veterans Affairs system, the Indian Health Services system and a major Catholic healthcare system do not allow PAS in their facilities.3 Some physicians willing to prescribe the medication have had difficulty finding a second physician to confirm the prognosis or a pharmacist willing to fill the prescription.9

Some physicians fear being penalised if they prescribe a lethal medication. In November 1997 Thomas Constantine, head of the US Drug Enforcement Administration, stated that if physicians prescribed a lethal medication to end a person's life it would be a violation of federal law.17 Then, in June 1998, United States Attorney General Janet Reno ruled that physicians in Oregon could legally write such a prescription.18 (This may be one reason why the number of people using PAS was higher in 1999 than in 1998.) However, the US Congress is now considering a bill that would make it illegal for physicians to prescribe a controlled substance to end a person's life. Consequently, some physicians may consider it risky to write such a prescription, particularly as to do so remains against professional guidelines.9,19

People residing in small cities, particularly those in eastern Oregon who are 75-400 miles from Portland or another metropolitan area, may be severely disadvantaged in getting access to PAS. Ganzini et al9 found that it was extremely rare for physicians practising in areas of fewer than 25 000 people (94% of Oregon's cities have fewer than 25 000 people5) to prescribe the medication. Physicians who do not have a large population base from which to draw patients may fear that if they participate in assisted suicide they could be the target of demonstrations outside their homes and offices, similar to those directed at physicians who perform abortions.20 Two-thirds of the physicians writing a lethal prescription expressed concern about reporting the fact to the Oregon Health Division.9

Because many terminally ill people are confined to their bed or home, the difficulty of finding a physician to prescribe the medication may result in many people abandoning the idea of using PAS as an end-of-life option.

Conclusion

 Although PAS is legal for terminally ill people in Oregon, relatively few appear to have used medication to end their lives. The process of finding a physician willing to write the prescription, fulfilling all the legal requirements and finally receiving the medication can be time consuming, and perseverence is required. Once diagnosed with a serious or terminal illness, patients should probably start looking for a physician who is willing to prescribe a lethal medication if necessary. Without adequate planning for the possibility of using PAS, some terminally ill Oregonians may be unable to take medication to hasten their death.

References
  1. Oregon's Death with Dignity Act: three years of legalized physician-assisted suicide. Portland, OR: Oregon Health Division, 22 February 2001.
  2. Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon - the second year's experience. N Engl J Med 2000; 342: 598-604.
  3. Chin AE, Hedberg K, Higginson GK, Fleming DW. Oregon's Death with Dignity Act: the first year's experience. Portland, OR: Oregon Health Division, 18 February 1999.
  4. Haley K, Lee M, editors. The Oregon Death With Dignity Act - a guidebook for health care providers. Portland, OR: Oregon Health Sciences University, 1998.
  5. Wineberg H. Population estimates for Oregon: July 1, 1997. Portland, OR: Center for Population Research and Census, 1998.
  6. Center for Health Statistics. Oregon vital statistics annual report, 1997. Volume 2: Mortality. Portland, OR: Oregon Health Division, 2000.
  7. Center for Health Statistics. Oregon vital statistics county data 1998. Portland: Oregon Health Division, 2000.
  8. Van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705.
  9. Ganzini L, Nelson HD, Schmidt TA, et al. Physicians' experiences with the Oregon Death with Dignity Act. N Engl J Med 2000; 342: 557-563.
  10. Van der Maas PJ, Van Delden JJM, Pijnenborg L, Looman CW. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-674.
  11. Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998; 352: 1097-1102.
  12. Australian Bureau of Statistics. Deaths, Australia. Canberra: ABS, 1996, 1997. (Catalogue No. 3302.0). <http://www.abs.gov.au>.
  13. Lee MA, Tolle SW. Oregon's assisted suicide vote: the silver lining. Ann Intern Med 1996; 124: 267-269.
  14. Tolle SW. Care of the dying: clinical and financial lessons from the Oregon experience. Ann Intern Med 1998; 128: 567-568.
  15. Muskin PR. The request to die: role for a psychodynamic perspective on physician-assisted suicide. JAMA 1998; 279: 323-328.
  16. Groenewoud JH, Van der Heide A, Onwuteaka-Philipsen BD, et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med 2000; 342: 551-556.
  17. Hill GK, Barnett J. Push is on to assess DEA clout on suicide. Oregonian November 13, 1997: D1, D5.
  18. Hogan D. Bills blocking assisted suicide continue to move. Oregonian July 25, 1998: B1, B3.
  19. Lee MA, Ganzini L, Brummel-Smith K. When patients ask about assisted suicide: a viewpoint from Oregon. West J Med 1996; 165: 205-208.
  20. Lee MA, Tolle SW. Oregon plans to legalise suicide assisted by a doctor: how much more open will the practice become? BMJ 1995; 310: 613-615.


Authors' details

Portland, Oregon, USA.
Howard Wineberg, PhD, Private consultant.

Reprints will not be available from the author.
Correspondence: Dr H Wineberg, 1513 SE Oak Street, Portland, Oregon, USA 97214-1454.
wineberghAThotmail.com

©MJA 2001
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