To the People of California on the Realities of Physician-Assisted Suicide

Dear Friends and Neighbors:
Recently our major daily newspaper, The Oregonian, picked up and ran the story that Californians were debating a bill legalizing physician-assisted suicide, modeled on Oregon’s seven-year-old Death With Dignity Act (DWDA).

But It All Sounds So Sensible

I studied it thoroughly — not just because I have an interest in issues like these, but because I have an interest in California as well. Unlike some Oregonians who sport nasty bumper stickers about urban sprawl and the northward migration of a few of your citizens over the years, I like California. I was born in San Diego and lived there until I was almost four, and then in my twenties, I spent 18 months working for a record company in Newport Beach before moving back to Portland in 1992. California is a rich cultural treasure trove and an undeniably beautiful place. And, being a musician and actor, I’ve always felt a kinship with the southern California subculture, admiring its influence while smiling at its artifice.

Physician-assisted suicide, however, is a deadly serious subject. I want to take this opportunity to tell you what it’s like to live in a state where it’s legal (and somehow noble) to kill yourself for certain “acceptable” reasons. Right-to-die advocates present a picture of pain-wracked, horribly suffering people experiencing smooth, easy deaths following a foolproof medical consent and evaluation process. In reality, it’s not this way, and there are no guarantees that the process or the “safeguards” will work.

By now, you’ve all heard of the DWDA and its sensible-sounding requirements: a terminal illness, six months to live, three requests (one in writing), a second concurring medical opinion, self-administration of the drug overdose, no lethal injections. Over the past seven years that Oregon’s DWDA has been in effect, every single one of these walls against abuse has been breached.

Contrary to the assurances of “safeguards” and “monitoring,” here follows the chilling reality: Consider the case of Mrs. Kate Cheney, an elderly Oregon woman with unfortunate diagnoses of both dementia and cancer. Dr. Thomas Pitre in his article “Lessons from Oregon” (The Linarce Quarterly, May 2004), chronicles the events:

[Mrs. Cheney’s] daughter accompanied [Mrs. Cheney] to her doctor’s appointment to formally request assisted suicide under Oregon’s new law allowing such a practice; the doctor did not agree with that course of action. It was the daughter, not the patient, who then insisted the mother have a new doctor within her health maintenance organization, Kaiser Permanente. The doctor change for the mother was granted to the daughter.

This second doctor was willing to give Mrs. Cheney assisted suicide and arranged for psychiatric evaluation, because it was standard procedure at this health maintenance organization (HMO) in its assisted-suicide protocol. The psychiatrist, who released a written report to the newspaper, found that Mrs. Cheney had short-term memory deficits and dementia. He also said the assisted-suicide request appeared to be the daughter’s “agenda.” The daughter, who also accompanied Mrs. Cheney to this appointment, “coached her” in her answers, even when the psychiatrist asked her not to do so. The psychiatrist said, “[Mrs. Cheney] does not seem to be explicitly pushing for this.” She was deemed lacking sufficient capacity to weigh options about assisted suicide; thus, she was not eligible for doctor-assisted suicide. The patient accepted this assessment. Her daughter, however, “became angry.”

It was the daughter, not the patient, who then “decided on a second competency evaluation.” Kaiser HMO apparently authorized this second off-panel mental health evaluation. This new psychologist admitted that the patient could not even remember when she was diagnosed with terminal cancer, although it had only been within the last three months. She also wrote that the patient’s “choices may be influenced by her family’s wishes and her daughter, Erika, may be somewhat coercive.” Nevertheless, she approved the assisted suicide.

With two conflicting mental health opinions, the final decision, far from being an “autonomous” decision made in “private” by the patient, came down to yet another Kaiser HMO doctor-administrator, Robert Richardson, who approved giving a lethal overdose to this elderly woman under pressure from her family.

This is no scare-tactics fantasy; this was thoroughly and publicly documented. Safeguards were meaningless in this case. This incident shows that if someone wants assisted suicide badly enough, or if they want it for someone else badly enough, any barrier can be got around. After all, this is about personal autonomy, isn’t it? If you want something, no law can stand in your way — right?

The official documents describing the Oregon Health Plan (Oregon’s version of Medicaid) clearly indicate the funding priorities of the state, placing “end of life care” (which now includes assisted suicide) above “community mental health.” This means that if you have the misfortune to be both terminally ill and poor, the state’s health care bureaucracy will most likely consider paying for your overdose of pentobarbital before your prescription for Prozac. (I note that your own state legislators have attempted some similarly motivated sleight-of-hand with AB 651, a bill originally designed to provide health care to the poor but now more reflective of the pro-suicide lobby’s priorities.)

Speaking of suicide drugs, according to the 2004 Oregon Department of Human Services Death With Dignity annual report, pentobarbital is the most popular drug used in assisted suicide. This drug is available only in a liquid form designed for injection. This raises a question: Are people really shooting themselves up, or is this drug being purposely misprescribed by doctors who support PAS and being taken orally? (The Oregon DWDA specifies that the patient must be able to swallow the medication.) The report also notes that secobarbital (brand name Seconal) was used for several 2004 assisted suicides. However, Seconal was not being manufactured in this country during much of that year and was difficult to obtain even with a prescription. Where did all these people get it? The DHS report seems to raise more questions than it answers when examined closely.

Complications and Uncertainties

As with any medical procedure, complications have sometimes arisen. (For the purpose of our discussion, a “complication” means that the patient didn’t die as expected.) When problems are reported, they usually reflect the inconsistent effects of the lethal medication dosage. For example, The Oregonian reported that in January of this year, David E. Prueitt, a 42-year-old man with lung cancer, downed the contents of 100 Seconal capsules mixed with applesauce and water, expecting to end his life. He was comatose for nearly three days. When he awakened, he spoke the following choice words: “What the hell happened? Why am I not dead?” He wisely decided, along with his family, not to try again; he died a natural (one might say dignified) death two weeks later.

An earlier case concerns Patrick Matheny, who in 1999 lived on the southern Oregon coast and suffered from amyotropic lateral sclerosis (ALS), a neurological disorder. He received his lethal prescription via mail order, and since nothing in the Oregon law requires medical personnel to be present during the assisted suicide, he did his best to concoct the potion properly and drink it on his own. However, one of the difficulties caused by ALS is trouble with swallowing. As The Oregonian reported the story, his brother-in-law indicated that Mr. Matheny was ultimately unable to self-administer the medication and had to be “helped” to die. To this day, no one knows what “help” he was given; no official reporting was required, the family’s not talking, and Mr. Matheny’s body was cremated the next day. Don’t be fooled; the secrecy that the DWDA promised to dispel is still quite thick.

Doctors in the Netherlands, who have had the most experience with this sort of thing, estimate that “complications” occur in up to 20% of assisted suicide cases. This is why they rely on the availability of lethal injection. (Of course, the Dutch are involuntarily euthanizing handicapped children now — but we’re too civilized to do that.) We’re just lucky that Mr. Matheny’s relatives didn’t sue the state for discrimination based on the Americans with Disabilities Act, due to Mr. Matheny’s inability to swallow. Thus, Oregon teeters on the edge, just one court case away from legalizing lethal injection. Here’s what you call “the money quote” from an Oregon doctor, Peter Rasmussen, who has been involved in numerous assisted suicides: “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.” That wind we Oregonians feel in our faces isn’t the one coming down from Mt. Hood through the Columbia Gorge; it’s from our momentum as we slide further and further.

Also, let me warn you that if you ever are given a chance to vote on this issue in a general election, you will endure an avalanche of local TV and radio campaign commercials touting the “compassionate” and “loving” choice of assisted suicide. As you do, remember the artifice of Hollywood I mentioned earlier. During the 1994 campaign to legalize PAS in Oregon, a television commercial was aired featuring Patty Rosen, RN. She told the heartbreaking story of her decision to help her daughter, who was dying of thyroid cancer, to die via an overdose of illegally-obtained medication. In the ad, she said that her daughter died peacefully from the lethal overdose. However, three days before the election, it was discovered that Ms. Rosen hadn’t told the truth; her daughter did not die from the drug overdose, but from a lethal injection Ms. Rosen administered. Again, this is the reality of assisted suicide on the ground. Amidst the rhetoric of “compassion”, make sure to fact-check what the campaigns feed you.

Besides the uncertainties involved in administering assisted suicide, many terminally ill people don’t seem to cooperate with their six-month prognoses; some have improved and lived for years, and some have worsened suddenly and died within days. Studies have shown that when doctors make such determinations, they are wrong up to 40% of the time. When my own mother-in-law was dying of cancer in 2004, various health professionals and family members made wildly divergent predictions of her future. The wisest words that I heard at that time were spoken by a doctor whom I know well, a retired psychiatrist familiar with physicians’ habits and quirks. He told me, “The closer a person is to death, the less the doctors know.”

Depressed, Disabled, Disposable

Oregon PAS supporters make much of the fact that there has not been a “rush” of terminally ill people to commit suicide, as some opponents had feared. The annual report on physician-assisted suicide published by the Oregon Department of Human Services states that the number of cases actually decreased in 2004 compared to previous years; there were 37 assisted suicides in 2004 compared to 42 in 2003, and 60 lethal prescriptions written in 2004 compared to 68 in 2003. This has been cited in multiple press outlets to allay fears of that slippery slope. However, one fact in the report you’re not likely to hear from PAS supporters is that referrals for psychological evaluations for these suicide-minded people have also sharply decreased. In 1998, the first full year of legalization of assisted suicide in Oregon, the Department of Human Services reported that of the 15 people who died that year as a result of PAS, four had been referred for psychological evaluation. Last year, of the 37 people who committed suicide in this way, only two were given psychological referrals. This supposed safeguard is crumbling fast because 1) suicide-minded patients are beginning to seek out doctors whom they know to be assisted-suicide advocates; 2) these few physicians are writing a disproportionate number of lethal prescriptions; and 3) these physicians, because of their philosophical stance, don’t recognize their patients’ depressive symptoms as indications of a need for psychiatric care.

Dr. Peter Rasmussen (quoted above) was one of the plaintiffs in Oregon’s successful lawsuit to preserve assisted suicide in the face of Attorney General John Ashcroft’s 2001 ruling against it, and he has written several lethal prescriptions since the law took effect. In a recent interview with American Medical News (the newletter of the American Medical Association), Dr. Rasmussen states, “In my practice as an oncologist and palliative care physician, most of my patients are exhibiting some signs and symptoms of depression because many of these overlap with being terminally ill.” In other words, he regards psychiatric indicators of depression, including the wish to die, as normal for someone with terminal illness. Yet, he insists that his practice is “not a prescription mill” and that “most oncologists and people who spend a lot of time with the terminally ill are getting good at picking up clinical depression.” He regards his own informal judgment as adequate in the matter, despite the fact that he is not a licensed psychologist or psychiatrist as the law requires, and despite the fact that the Oregon Death With Dignity Guidebook for Health Care Professionals recommends that all patients inquiring about physician-assisted suicide be referred for psychological evaluation.

Beck’s Depression Inventory is a standard questionnaire used by psychiatrists and psychologists in evaluating patients for clinical depression. Its list of depression symptoms includes thoughts or plans of suicide. This reflects basic principles of psychology which insist that a wish to die is not a neutral or normal thought, though it often coincides with times of great personal stress or loss. Suicidal thoughts are a sign of depression, and if they appear in combination with other symptoms and persist over a long period of time, they are a strong indicator of clinical depression. Clinical (or major) depression is a severe mood disorder caused by an imbalance of brain chemicals, often corrected successfully with strong psychoactive drugs. (This is different than the less severe, temporary, situation-based type of depression which is often intermixed with the grieving process and improves with talk therapy or simply the passage of time for adjustment.) In any case, from a psychiatric point of view, thoughts and plans of suicide are part of a temporary or at least treatable emotional disorder; they are, at the root, irrational. In all of the psychiatric literature from Freud to the present, there has never been proposed any such thing as a rational wish to die — until now. To date, assisted suicide advocates have never addressed the fact that the “right to die,” as they conceive it, is a brand-new philosophical construct that contradicts 100 years of established psychological theory.

The Oregon law incorporates another supposed safeguard — a 15-day waiting period between the first request for lethal medication (three are required) and receipt of the prescription. According to the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition (DSM–IV) and Beck’s Depression Inventory, 15 days is barely enough time for a mental health professional to fully assess the character of a patient’s depressive symptoms. Also, it’s nowhere near enough time for an ordinary person to take in and adjust to a doctor’s sad prognosis regarding his/her terminal or chronic illness. No one pretends that cancer, ALS, and multiple sclerosis aren’t the frightening, debilitating, and painful conditions that they are. However, it does take time to weigh the options for palliative care and treatment, to evaluate the success or failure of such options, and to fully consider the meaning of one’s life in the context of family, spirituality, and community. Considering the wealth of every human lifetime, a mere two weeks is not enough time for making a decision and arrangements to throw it all away.

Those people who pursue physician-assisted suicide in Oregon are asked to fill out a questionnaire as part of the reporting process and to indicate on it their reasons for choosing to die. The issues of “loss of autonomy” and “loss of ability to participate in activities that make life enjoyable” consistently top their list of concerns. Consider, though, all the different types of situations in which a person may find himself or herself without “autonomy” (however defined) or the ability to engage in pleasurable activities. A two-year-old girl has quite limited autonomy in terms of self-determination and decision-making; is such a state unbearable for her? A prison inmate is prevented from associating with former colleagues and can no longer engage in the life- or property-destroying activities he once did — can he not choose to do other things? When we enter into stages of life in which our need for others’ support and care is great, or greater than before, does our dependence cause an automatic decrease in our dignity as human beings?

In his famous sermon, John Donne said, “No man is an island”; supporters of assisted suicide seem firmly to believe the opposite. They regard any need for others to care for them as the greatest horror, the greatest cause of suffering, to be avoided at any cost. This raises the question: Can this sort of “suffering” really be avoided? Does such a radically self-reliant attitude actually improve our society, or does it in fact diminish us as a human community?

Disability rights groups (such as the one cheerily named Not Dead Yet) boldly carry the banner against assisted suicide, and this is the reason: They deal every day with personal issues of loss of autonomy, loss of control of bodily functions, loss of former physical or mental abilities, and many others. And yet, they insist that their lives are worth living. They insist that they are dignified human beings. Every time someone sounds off using the media’s megaphone with some version of “I wouldn’t want to live in that state,” it’s as if that person had walked up to a wheelchair-bound or mentally ill person on the street and said right to his or her face, “You know, don’t you think you'd be better off dead?” This is compassion?

So, my California friends, now it’s your turn to debate the pros and cons of assisted suicide — in the newspaper and local news, in Sacramento and at your neighborhood Starbucks. You’re now armed with knowledge and experience that we in Oregon didn’t have when we started this experiment. I hope you won’t follow us into the dark.

© Copyright 2005 Catholic Exchange

Kathleen Lundquist lives in Portland, Oregon. After journeying through many forms of Protestantism, she and her husband Gary were confirmed in the Catholic Church in 1999. She is a musician and songwriter as well as an author of poetry and essays on art, music, popular culture, and life issues.

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