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Vermont House Human Services Committee
Representative Ann Pugh, Chair

Hearing on H-168
Proposal to legalize physician-assisted suicide in Vermont
April 14, 2005, Testimony by Telephone

Testimony of Kenneth R. Stevens, Jr., M.D.
Vice President,
Physicians for Compassionate Care Education Foundation
Professor and Chair, Department of Radiation Oncology
Oregon Health & Science University, Portland, Oregon

I have been in the practice of Radiation Oncology, treating cancer patients, for 38 years in Oregon. I have been Professor and Chair of the Department of Radiation Oncology at Oregon Health & Science University for 16 years.

I have studied Oregon's assisted-suicide law since its passage in 1994. The more I have learned, the more I realize the significant harm and danger of assisted suicide to the vulnerably ill and to society.

ASSISTED SUICIDE IS DOCTOR-DIRECTED SUICIDE

Physician-assisted suicide represents a reversal of the proper role of physician as "healer, comforter, consoler", to an improper role of helping patients commit suicide. Physician-assisted suicide is really doctor-directed suicide, because the prescription is a written directive or order to the patient.

The false message of assisted suicide proponents is that doctors can do a better job of killing patients than they can of caring for their medical needs.

MY WIFE'S EXPERIENCE

I have personal experience regarding this matter. My wife had been suffering for three years from advancing malignant lymphoma. In May 1982, we met again with her physician to see what more could be done for her. It was evident that not much more could be done other than comfort care. As we were about to leave his office, her physician said, "Well, I could write a prescription for an 'extra large' amount of pain medication for you." He did not say it was for her to hasten her death, but she and I both felt his intended message. We declined the prescription, since her current pain medication was sufficient. As I helped her to our car, she said, "He wants me to kill myself!" She and I were devastated. How could her physician, her trusted physician, subtly suggest to her that she take her own life? We had felt much discouragement during the prior three years, but not the deep despair that we felt at that time when her physician subtly suggested that her suicide be considered. Six days later she died naturally, with dignity and at ease in her bed, without the suggested medication.

Assisted suicide destroys the trust between patient and doctor.

PAIN IS NOT THE ISSUE

There is not one instance in Oregon of assisted suicide being used for actual untreatable pain. Assisted suicide is being used for psychological and social concerns.

AUTONOMY AND CONTROLLING PEOPLE

The great majority of those dying of assisted suicide in Oregon have been upper-middle class Caucasians. Oregon assisted-suicide patients have been described by their doctors as being fiercely independent and controlling. Society should always fear laws that are established by and for controlling people. History has taught us that once such laws are established, the poor and vulnerable are discriminated against.

It is not surprising that the black community is much less likely to favor assisted suicide compared to the white community. Families of Oregonians dying between June 2000 and March 2002 were interviewed regarding assisted suicide. Whereas 18% of the dying whites personally considered assisted suicide (none of these people used assisted suicide), there was not one of 62 blacks that considered it.1 There have been no black deaths among the 208 deaths in Oregon between 1998 and 2004.3

THE PROBLEMS WITH "SAFEGUARDS"

Assisted suicide proponents talk about the "safeguards" with Oregon's assisted suicide law. The fact that the word "safeguards" is used, is an indication that assisted suicide is dangerous and unsafe for the general public. The so-called "safeguards" are really boundaries or restrictions around assisted suicide. They may be considered as a means of protection against abuse, but they also act as a barrier or restriction to those who find themselves outside those boundaries.

AUTONOMY AND SAFEGUARDS DON'T MIX

When persons desiring assisted suicide finds themselves outside the boundaries that are written in the law's "safeguards", they want to bypass or stretch the boundaries. This is especially true of people who have been described by their doctors as being extreme in their desire for control of their lives and death.

The so-called "safeguards" or boundaries in the Oregon law are:

  • Diagnosis of a terminal illness; less than 6 months to live.
  • Mentally capable.
  • >18 years of age.
  • Lethal drugs self-administered and taken by mouth.
  • Lethal injection not permitted.

OREGON'S ASSISTED SUICIDE "SAFEGUARDS" ARE NOT BEING FOLLOWED

With virtually every case that has come to public light, the closer one looks at individual cases, the uglier is the reality.

The assisted suicide law provides no protection for the depressed or mentally ill. Shockingly, only 5% of those dying from assisted suicide in 2003 and 2004 had a mental health consultation.2, 3

In Oregon, patients with mental disorders can receive lethal drugs to kill themselves. Nationally, the majority of forensic psychiatrists believe that the presence of major depressive disorder should result in an automatic finding of incompetence.4

Kate Cheney was a woman in her 80s with cancer who requested assisted suicide. After a psychiatric evaluation determined that she had dementia and was not mentally capable, she and her family sought a psychologist's evaluation that felt that she was capable. This is an example of "doctor-shopping" to get a desired opinion. She finally received the prescription for lethal drugs from a Kaiser HMO doctor.5

Michael Freeland was a 62-year old man newly diagnosed with lung cancer, and with a history of depression and prior suicide attempt. He received lethal drugs from an assisted suicide doctor without a mental health consultation. He was later admitted to a psychiatric ward. When he was discharged from the psychiatric ward, the doctors and court judged him incompetent. Yet this man had a bottle of lethal drugs in his house.6 Was this safe? Where were the safeguards?

Jake Harris was a man with multiple tumors in his brain, whose thinking was slipping and parts of his brain were blinking off. And in that condition he received the lethal medication.7

Patrick Matheny8 and Barbara Houck9 were patients with ALS (Amyotropic Lateral Sclerosis), who had problems swallowing and being able to self-administer the medication. Mr. Matheny had to be "helped" by his brother-in-law because of his trouble swallowing. Mrs. Houck had the lethal medication spoon-fed into her mouth. Where was the self-administration in these cases?

Determining that a person has less than six months to live (terminal) is fraught with error. Some Oregonians who have received the prescriptions for lethal medication have lived far longer than 6 months, some for more than 2 years.

The "slippery slope to euthanasia" has occurred in Oregon. In 1996, a doctor in Corvallis, Oregon had a patient die from lethal injection (euthanasia). He was not criminally prosecuted and his medical license was suspended for only two months.10 The county district attorney did not prosecute the case because he felt the political climate of having legal assisted suicide in Oregon would prevent a conviction for euthanasia.

Many doctors are writing prescriptions for lethal drugs to patients for whom they have not previously cared. Dr. Peter Rasmussen reported that "75% of the patients who come to him regarding assisted suicide are people he has never seen before". Regarding the "slippery slope" of assisted suicide, Dr. Rasmussen said, "I think all involved in the Oregon law must recognize that we are on a slippery slope, and we have to be careful with every step. But just because it's a slippery slope doesn't mean we shouldn't go there." 11

THERE ARE FAILED ASSISTED SUICIDES IN OREGON

"Why am I not dead?" read the headline of the March 4, 2005, The Oregonian newspaper.12 "An Estacada [Oregon] man's attempt at doctor-assisted suicide took a bizarre turn when he [David Pruiett] woke from a coma nearly three days later and lived for two more weeks."

This was not the first case of a failed assisted suicide attempt. In 1999, a man had problems after taking the pills, his wife called 911, he went to a hospital, and later died in a nursing facility of natural causes.13 Yet this failed physician-assisted suicide was not reported in the 2000 year report from the Oregon state agency.

THERE ARE OTHER COMPLICATIONS IN OREGON

In 2003, a patient drank only one-half of the lethal medication, and then vomited one-third of what he had taken, and he lived 48 hours before finally dying.2 What was the true cause of death, since he had taken a less-than-lethal-dose of short-acting barbiturate? In 2004, at least 3 patients vomited , and 4 patients lived from 7 ½ to 31 hours after taking the drugs.3 This is not surprising since Dutch doctors have cautioned that death with assisted suicide is not always easy or peaceful, with complications occurring up to 20% of the time.

THERE IS SECRECY REGARDING WHAT IS HAPPENING IN OREGON

There is lack of proper oversight of Oregon's assisted suicide by the Oregon Department of Human Services. A March 8, 2005, Oregonian newspaper editorial, in referring to the relative lack of reported complications in Oregon's assisted suicide law, stated: "But how can we be for sure? As the Pruiett case shows, the people reporting the central facts of the [Oregon] experiment are not disinterested. The results must be considered suspect because they may be shaded by people who, for various reasons, want things to seem fine.. The facts must be allowed to emerge through objective assessment. This case demonstrates that Oregon's mechanism for that simply doesn't exist." 14

According to the Compassion in Dying organization, about three-fourths of those dying from assisted suicide in Oregon are doing it under the direction of that organization. That organization has a vested interest in not reporting complications or problems.

THERE IS NO REAL MONITORING OF OREGON'S ASSISTED SUICIDES

When Mr. Pruiett's failed assisted suicide was made public, the Oregon Department of Human Services (DHS) publicly stated that they had "not authority to investigate individual Death with Dignity cases. The state law authorizing physician-assisted suicide neither requires or authorizes investigations by DHS." 15

We are dependent on self-reporting by doctors, and in over 70% of assisted-suicide deaths in 2003 & 2004, the prescribing doctors were not there when the patients took their lethal medications, so how do they know what happened at the time of death?2, 3 They don't. This information is obtained second or even third hand. The Oregon State Dept. of Human Services has commented that what they receive from doctors might be a "cock and bull story".16 We really do not know what is going on in Oregon.

INJECTABLE PENTOBARBITAL IS BEING USED FOR MOST ASSISTED SUICIDES

In 2003 and 2004, 78% (62/79) of the Oregon assisted suicide deaths were from pentobarbital. Pentobarbital is currently only available in a liquid formulation. It is officially named "pentobarbital sodium injection, USP; Nembutal sodium solution". Its only indication and usage is as an intra-muscular or intra-venous injection. It is not designed for FDA authorized for oral ingestion. Now that this form of lethal barbiturate is being used for assisted suicide, there is nothing to prevent its use by lethal injection, which is illegal in Oregon.

FINANCIAL AND SOCIETAL DANGERS,

ASSISTED SUICIDE MAY BECOME THE ONLY CHOICE FOR SOME PATIENTS

In Oregon, for a patient with cancer with a less than 5% chance of living 5 years, Medicaid (Oregon Health Plan) will only pay for "Comfort Care", which includes assisted suicide. Based on the Prioritized List of Medical Services, Oregon Medicaid will not pay for curative medical or surgical cancer treatment services for patients with a less than 5% chance of living 5 years.

In 2003, Oregon Medicaid stopped paying for medicines for 10,000 Oregonians who had been on Medicaid (Oregon Health Plan). This included patients with AIDS, bone marrow transplants, mentally ill and those with seizure-disorders.

A physician member of Physicians for Compassionate Care received a phone call in the spring of 2003, from a man requesting assisted suicide. The man said, "The state of Oregon Medicaid has stopped paying for the pain meds I take for my chronic back pain. If they won't pay for my pain meds, they might as well pay for my suicide."

In December 2004, the Oregonian newspaper reported that 50.000 Oregonians had been cut from the Oregon Health Plan, and that the state plans to cut another 25,000 Oregonians from the plan by June 2005, to keep the state budget balanced.17

These cutbacks in medical-care financial support are killing Oregonians. It was reported in The Oregonian newspaper in December 2002 that there had been 94 mental health-related deaths because of the state cutback in mental health services.18

The vulnerable poor of Oregon have very limited access to health care. Sixty percent of Oregon doctors limit or do not see Medicaid patients. More than 40% of Oregon physicians limit or do not see Medicare patients.19

With all of these problems with reduction in health care to the vulnerably poor in Oregon, the Oregon Health Plan (Medicaid) continues to pay for physician-assisted suicide. We are concerned that assisted suicide may become the "only choice" for some vulnerable and ill patients.

END-OF-LIFE CARE IS MIXED IN OREGON

Assisted suicide proponents erroneously claim that the legalization of assisted suicide has made Oregon a leader in the care of dying patients and in the use of pain medication. The facts do not support those claims.

Oregon ranked high in per capita use of morphine before assisted suicide became legal. Many other states have enacted or strengthened laws to ban assisted suicide, and per capita use of morphine in those states has increased in every case.20

A national organization, "Last Acts", issued a "report card" in November 2002 to states regarding their end-of-life care. Oregon was given a "D" grade for hospice (less than 1/3rd of dying Oregonians used hospice), and an "E" grade for palliative care programs.21

Regarding assisted suicide patients who want nothing to do with hospice care, Ann Jackson, Executive Director of the Oregon Hospice Association, in a 2003 Oregonian newspaper interview, said, "In effect, they've said no to hospice, either because they don't believe we in hospice can meet their needs, or we're not meeting their needs."22

After four years of assisted suicide in Oregon, there were almost twice as many dying patients in moderate or severe pain or distress, as there had been prior to Oregon's assisted suicide law being used.23 Those who erroneously blame the increase in pain and distress on the DEA directive of Nov. 6, 2001, fail to realize that only one-fourth of the June 2000 to March 2002 time period occurred following the date of that directive.

COMPARISON OF ASSISTED SUICIDE RATES BETWEEN STATES

There has been a false claim that Oregon has a lower assisted suicide rate than that of other states.24 There is no truth to that report. Dr. William Toffler and I have recently written an article that shows that we do not know what the assisted suicide rate is in states other than Oregon.25 There is no evidence that legalization of assisted suicide in Oregon has decreased the rate of physician-assisted suicide.

Oregon continues to have a high suicide rate among the elderly. Oregon has a suicide rate (excluding assisted suicide) of the elderly (65 and older) that is one and a half times the national average.26

CONCLUSION

I hope you will learn from the problems with physician-assisted suicide in Oregon. Assisted suicide is not needed, and it puts vulnerable people at risk. The citizens of Vermont need to concentrate on improving end-of-life care and palliative-care programs, and not on promoting unnatural assisted suicide.



1 Tolle SW, Tilden VP, Drach LL, Fromme EK, Perrin NA, Hedberg K. Characteristics and proportion of dying Oregonians who personally consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
2 Sixth Annual Report on Oregon's Death with Dignity Act, Oregon Department of Human Services, March 10, 2004, www.ohd.state.or.us/chs/pass/ar-index.cfm.
3 Seventh Annual Report on Oregon's Death with Dignity Act, Oregon Department of Human Services, March 10, 2005, www.ohd.state.or.us/chs/pas/ar-index.cfm.
4 Ganzini L, Leong GB, Fenn DS, Silva JA, Weinstock. Evaluation of competence to consent to assisted suicide: Views of forensic psychiatrists. Am J Psychiatry. 2000; 157:595-600.
5 Barnett EH. Is Mom capable of choosing to die? The Oregonian. October 17, 1999.
6 Hamilton NG, Hamilton C. Competing paradigms of responding to assisted suicide requests in Oregon: Case report. American Psychiatric Association Annual Meeting Symposium on Ethics and End-of-Life Care: New Insights and Challenges, New York City, May 6, 2004. To be published in Am J Psychiatry, April, 2005. (available at www.pccef.org, May 6, 2004)
7 Klare S. Jake Harris, in Compassion in Dying, edited by BC Lee (Troutdale, Oregon, NewSage Press), 2003, p 102.
8 Barnett EH. Man with ALS makes up his mind to die. The Oregonian, March 11, 1999.
9 Frey J. A death in Oregon: One doctor's story. Washington Post, November 3, 1999.
10 American Medical News. Board sanctions physician for 'active euthanasia'. August 11, 1997.
11 Robeznieks A. Oregon sees fewer numbers of physician-assisted suicides. American Medical News April 4, 2005.
12 Don Colburn, Why am I not dead?, The Oregonian, March 4, 2005.
13 Hamilton C. What's hiding behind the numbers?. Brainstorm March 2000, pp 36-38.
14 Editorial. Living with the dying 'experiment'. The Oregonian. March 8, 2005.
15 No authority to investigate Death with Dignity case, DHS says. Oregon DHS News Release March 4, 2005.
16 CD Summary, A year of dignified death, Oregon Health Division, March 16, 1999, Vol 48, No. 6.
17 Beggs CE. Governor proposes small school aid boost, new lottery games. The Oregonian. The Associated Press. December 1, 2004.
18 Roberts M. Did they have to die? The Oregonian. December 29, 2002.
19 Survey shows patient access problem grows. The Scribe. Published by the Medical Society of Metropolitan Portland. November 19, 2004.
20 Americans for Integrity in Palliative Care: Written testimony presented to the American Medical Association Annual Meeting, June 10, 2003.
21 Last Acts, Press Release, November 18, 2002.
22 Colburn D. Suicide: Study is based on interviews. The Oregonian. June 12, 2003.
23 Fromme EK, Tilden VP, Drach LL, Tolle, SW. Increased family reports of pain or distress in dying Oregonians: 1996 to 2002. J Palliative Med 2004;7:431-442.
24 Ganzini L, Dobscha SK. Clarifying distinctions between contemplating and completing physician-assisted suicide. J Clinical Ethics 2004;15:119-122.
25 Stevens KR, Toffler WL. Comment on Ganzini and Dobscha regarding comparing rates of physician-assisted suicide in Oregon with that of other states. J Clinical Ethics 2004;15:363-364.
26 CD Summary, Elder Suicide in Oregon, Epidemiology Publication of the Oregon Department of Human Services, February 22, 2005, Vol. 54, No. 4.

 


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