The Movement That Won’t Die

Physician-assisted suicide is defined as “a patient self-administering a lethal dose of an oral medication that has been prescribed by a physician,” according to Physicians for Compassionate Care, a group that operates out of Oregon.

The Netherlands was the first country to introduce the concept of assisted suicide almost 20 years ago, finally legalizing it in 2002, which paved the way for euthanasia—the direct killing of patients by lethal injection or dosage, with or without their approval, whether because of terminal illness or merely because of “unbearable or unrelieved suffering.”

Some 2,000 Dutch die by euthanasia every year; nine hundred are euthanized without their permission. Belgium followed the Netherlands’ lead in 2003. Luxembourg—a country of 480,000 people, 87 percent of whom are Catholic—is the third European country to legalize assisted suicide/euthanasia, passing it by a 30-26 vote in their parliament this past February.

In the US, the movement began with Washington state’s attempt to pass Initiative 119, which favored physician-assisted suicide and which was rejected by voters 17 years ago. Since then, physician-assisted suicide has ricocheted from state to state—25 in all—failing passage by voters or legislators, often repeatedly. Oregon, the only exception, legalized physician-assisted suicide in 1994.

In 2008, physician-assisted suicide legislation reappeared for the sixth consecutive year in the Arizona legislature, and in Wisconsin’s legislature for the 16th time. Neither bill is expected to be made into law in the near future.

In California , lawmakers failed to reintroduce a bill to legalize assisted suicide in February of this year because they lacked enough votes for it to be approved and for it to survive through the full assembly by a legislative deadline. This was the fourth year in a row such legislation had been introduced in the California assembly since voters rejected California’s Proposition 161 in 1995.

WASHINGTON STATE TRIES AGAIN

With this latest failure to pass a California assisted suicide law, Carol Hogan, California Catholic Conference communications director, predicted that the assisted suicide debate—and the funding for it—would now shift to Washington. The prediction came true on January 9, 2008, when 71-year-old former Washington governor Booth Gardner filed an assisted suicide initiative.

Getting the necessary 225,000 signatures for the initiative to appear on the November 2008 ballot, and getting them by this July, will be his “last campaign,” Gardner said. The fact that he has suffered from Parkinson’s disease for the last 15 years was part of the reason he decided to go ahead with the initiative campaign, he claims.

“I just feel very strongly that I ought to have control over my life. I hate to lose control. That’s just my nature, and a lot of people feel that way,” Gardner said after completing paperwork for the “Death with Dignity Act.” Ironically, since Parkinson’s is not considered a terminal illness, Gardner would not be eligible for assisted suicide under this new legislation.

With the help of his primary sponsor, Compassion and Choices of Washington—a state chapter of the renamed Hemlock Society— Gardner has created a political action committee called It’s My Decision. This newly formed non-profit is supported by such sympathetic organizations as the American Civil Liberties Union. So far it has raised $900,000, hoping for a campaign war chest of around $5 million.

Meanwhile, the Coalition Against Assisted Suicide is also working to raise funds and awareness across the state. Its members include disability rights advocates, physicians, nurses, hospice workers, minority groups, religious organizations, and other concerned citizens.

Coalition spokesman Duane French is a quadriplegic who heads the Washington chapter of Not Dead Yet. Paralyzed by a diving accident as a teenager, French fears not only that such legislation “opens the door for abuses,” but that there is “an agenda that goes well beyond people with terminal illnesses. People with disabilities are next on their list.”

He went on to explain that “Booth [Gardner] has already acknowledged he would prefer the law be far broader—but they have to start somewhere.”

French disagrees with Gardner’s stated concern about “control” being the primary incentive. What is more likely, he believes, is that “others don’t see value in your life.” So the assisted suicide campaign “is fueled by fear and feeds the forces of prejudice and discrimination against the terminally ill, seniors, and people with disabilities.”

Gardner’s 45-year old son, Doug Gardner, a born-again Christian, also vehemently opposes his father’s campaign. Current Governor Christine Gregoire is personally against the idea, saying that it is “ very difficult to support,” while admitting that she wouldn’t actively oppose the initiative as she doesn’t wish “to impose my morality on others.”

The Washington State Medical Association officially opposes physician-assisted suicide, according to spokeswoman Jennifer Hanscom, who explained that the organization “looks at it from the standpoint of how care should be improved at the end of life so people aren’t forced to make that decision.”

The Washington Hospice and Palliative Care Organization and the Washington State Hospital Association have also rejected Gardner’s campaign.

ANALYZING INITIATIVE 1000

Washington’s Initiative 1000, the “Death with Dignity Act,” duplicates Oregon’s physician-assisted suicide law. And like the Oregon bill, it is fraught with problems.

Rita Marker, executive director of the International Task Force on Euthanasia and Assisted Suicide, has analyzed the initiative, which classifies a lethal drug overdose as a medical treatment option and permits a doctor to help a patient commit suicide if he has a life expectancy of six months or less. She finds that under the initiative:

• Physicians are not required, but only encouraged, to notify family members in advance of a patient taking the lethal prescription.
• There are no safeguards for the patient once the prescription is written, no monitoring required to insure the competency of the patient at the time of the overdose, and no checking for overt pressure or force being applied to the patient to take the drug against his will.
• Government health programs, managed care programs, and HMOs are allowed to approve prescriptions for health care cost-cutting purposes.
• Although coercion and force are prohibited, there is nothing preventing a physician from suggesting or encouraging patients to use assisted suicide.
• Doctors are permitted to prescribe lethal barbiturates for mentally ill or depressed patients. A referral for counseling is only necessary if the attending or consulting physician believes a patient may be suffering from a psychiatric or psychological disorder or depression that “ caus[es] impaired judgment.” If the counselor believes the patient’s judgment is not impaired, the lethal prescription may be issued.
• Although physicians are required to report assisted suicide deaths to the state, there are no penalties for not reporting them or for filing incomplete or inaccurate reports.
• A patient must make two oral requests and one witnessed, written request for assisted suicide. The two oral requests (which need not be witnessed) can be phoned in, the written request can be mailed to the doctor, and the doctor can fax the prescription to a pharmacy, where the patient—or someone designated as the patient’s agent—can pick it up.
• Using the term “suicide” is not allowed. All state agencies must refer to assisted suicide as “obtaining and self-administering life-ending medication.” Death certificates must refer to the cause of death as the illness the patient was diagnosed with before dying by assisted suicide.

SUICIDE BY ANOTHER NAME

This final stipulation in the law was put in place when it was determined that the word “suicide” is upsetting to people. A Gallup poll, following the failure of yet another California assisted suicide bill (AB 654 in 2005), forced a change in tactics, according to an LA Weekly article, “The Semantics of Assisted Suicide Aid in Dying.” The April 2007 article reported that “58 percent of respondents supported ‘doctor-assisted suicide,’ yet after replacing the phrase with ‘physician aid in dying,’ that number jumped to 75 percent.”

This inspired Compassion and Choices to initiate “a nationwide campaign to expunge the word ‘suicide’ from the right-to-die debate,” according to the article. Successful lobbying by CAC convinced the American Public Health Association “to adopt the ‘value neutral’ term ‘aid in dying.’”

This semantic tack showed up in Duane French’s recent unsuccessful court challenge to the wording of Washington’s Initiative 1000. In refusing to allow the words “physician-assisted suicide” to be used in the ballot or official voters’ pamphlet description, Thurston County Superior Court Judge Chris Wickham reasoned that “it is a somewhat loaded term,” believing the phrase “conjures up images of Jack Kevorkian.”

A March 2, 2008 Seattle Times story reported that “proponents argue that it’s inaccurate to call it suicide when a dying patient chooses to hasten death with a prescription.” Attorney for Initiative 1000 Jessica Skelton suggested that the word “suicide” is “politicized language” that “implies a value judgment and carries with it a social stigma.”

So instead of “suicide,” voters will read that Initiative 1000 would allow some terminally ill patients “to request and self-administer lethal medication” prescribed by a doctor.

“If people were not ashamed, they would call it what it is: assisted suicide,” French said. He believes the semantic move to be an attempt to hide the term because “society really hasn’t changed, and people don’t support it.”

OREGON’S REALITY CHECK

No matter the terminology, the experience of legalized assisted suicide in Oregon continues to supply voters and legislators alike with enough reasons to take a pass on similar legislation.

In 2006, Dr. William Toffler, National Director of Physicians for Compassionate Care Education Foundation (PCCEF) in Oregon, made a statement to the BBC concerning an upcoming vote in Britain’s House of Lords on a physician-assisted suicide bill (later defeated 148 to 100). He said: “There has been a profound shift in attitude in my state since the voters of Oregon narrowly embraced assisted suicide 11 years ago. A shift, I believe, that has been detrimental to our patients, degraded the quality of medical care, and compromised the integrity of my profession.”

Toffler noted the change in health care in the state, where patients “with serious illnesses are sometimes fearful of the motives of doctors or consultants.” One woman confided to him that she feared her oncologist “might be one of the ‘death doctors.’”

Toffler, who is also a professor of family medicine at Oregon Health and Science University in Portland, discussed the state’s increasing health care cuts. He regularly receives notices that “many services and drugs for my patients—even some pain medications—won’t be paid for by the state health plan.” The health coverage has been reduced for in-home palliative care as well. At the same time, he says, “assisted suicide is fully covered and sanctioned by the state of Oregon and by our collective tax dollars,” listing the procedure under “pain management.”

In fact, in 2003 the Oregon Health Plan dropped from their beneficiary list 10,000 low-income Oregonians—including patients with AIDS, those awaiting bone marrow transplants, the mentally ill, and those with seizure disorders. In the next two years, an additional 75,000 Oregonians were cut from the plan’s list.

According to the PCCEF website, 60 percent of Oregon physicians limit or do not see Medicaid patients; 40 percent limit or do not see Medicare patients. Seventeen percent of Oregonians are without health insurance, a statistic increasing at a rate faster than any other state over the past four years.

Even though Oregon has the sixth highest suicide rate among those over 65 years of age (excluding those who die from assisted suicide), less than 5 percent of assisted suicide recipients had mental health consultations between 2003 and 2005, and only two of the 46 patients who died by assisted suicide in 2006 were first referred for psychiatric evaluation.

The “safeguards” in the law insist that patients must be competent and capable of self-dosing, are not depressed, have made the choice without coercion, and have a life expectancy of less than six months. However, according to media accounts, many patients who have died through assisted suicide are depressed, have dementia, have been coerced, have swallowing problems, and have lived over a year after being determined eligible. There are accounts of patients and their family members “shopping” for physicians willing to prescribe high-dose barbiturates.

A study from June 2000 to March 2002 showed that there were twice the number of dying patients considered to be in moderate or severe pain and distress as there were prior to the passage of Oregon’s physician-assisted suicide law.

On March 18, 2008, the latest “Death with Dignity” report was released by the Oregon Department of Human Services. Shane Macaulay, M.D., a member of the Coalition Against Assisted Suicide, said that the report “is deeply flawed.”

“Numbers of reported prescriptions and deaths have tripled since the first year assisted suicide was legalized, with a 30 percent increase in just the past year,” Macaulay stated. Not one patient was referred for psychological evaluation, some patients were given lethal prescriptions after knowing the prescribing physician for less than a week, and one patient lived for a year and a half after receiving the lethal prescription, even though only patients with six months or less to live are allowed access to physician-assisted suicide.

These are the cases that are known, but, according to Macaulay, the real statistics “are shrouded in secrecy.” He said: “There is no way to verify the reliability of the reports issued by the state. Under Oregon’s assisted suicide law, the state has no authority to investigate abuses or physician noncompliance. It’s a listing of whatever was provided to them [by prescribing physicians] and nothing more.”

TAKE THE PLEDGE

Through a new effort called “Take the Pledge,” Physicians for Compassionate Care is trying to educate doctors on how to bring back integrity in the practice of medicine and the trust that is placed in them by their patients, especially those facing terminal illness. “A main strategy of the pro-suicide movement is to marginalize [physicians] because informed physicians are the largest obstacle to their cause,” according to PCCEF’s website.

“Take the Pledge” includes an adaptation of the Hippocratic Oath for doctors to download and display in their offices. It is a declaration that physicians care about their patients, and will care for them through their illness, “managing their symptoms, including pain.” It is a simple way for doctors to acknowledge where they stand on assisted suicide and give patients an opportunity to discuss their concerns. (View a copy at: http://www.pccef.org/ttp/download.htm) The PCCEF website also makes available “dignity conserving questions,” listing approaches physicians can use to ascertain how patients are dealing with end-of-life concerns.

Another important figure in the movement opposing assisted suicide is Eileen Geller, R.N., B.S.N. She has worked for more than 20 years in the Seattle area as a registered nurse in hospice and palliative care, later becoming founder and president of Consoling Grace and Consoling Communities. These organizations were created “ to be a resource to parishes, communities, and organizations, but also to any person who is struggling with illness, care-giving, or grief.”

Geller believes that a long-term solution must go beyond fighting initiatives to legalize assisted suicide, concentrating instead on something more fundamental. “Clearly we need to fight assisted suicide politically, but equally important, we need to build effective networks of community care that combat the culture of death that spawns such killing initiatives. To do one without the other is morally inconsistent with the core of our beliefs as made manifest in [John Paul II’s encyclical] The Gospel of Life,” she emphasized.

“Initiatives like I-1000 in Washington state masquerade under such terms as compassion and choice, using innocuous phrases like ‘death with dignity’ and ‘hastened death’” to hide from view the reality of “the unmerciful killing of those who are medically, socially, and economically vulnerable,” she said.

Geller sees a need, instead, for “compassion-in-action” and “loving kindness extended toward all those who are in the ‘market’ for assisted suicide.” We should be caring for the vulnerable, those who are alone and depressed, “who feel as if they are a burden to their families, their caregivers, and their fellow parishioners,” she said.

The Church in recent years has spoken out in ever-more explicit terms about euthanasia. In November of last year, Pope Benedict XVI spoke to participants at the 22nd international conference promoted by the Pontifical Council for Health Care Ministry, which dealt with “ The Pastoral Care of Elderly Sick People.” He remarked that euthanasia seems to be “ one of the more alarming symptoms of the culture of death that is advancing above all in the society of well-being.”

The Holy Father reminded his audience of John Paul II’s exhortation to scientists and physicians that they never resort “to the temptation to have recourse to the practices of shortening the life of the elderly or the sick, practices that would in fact result in forms of euthanasia.”

Pope Benedict also cited a passage from his recent encyclical on hope: “A society unable to accept its suffering members, and incapable of helping to share their suffering, and to bear it inwardly through ‘com-passion,’ is a cruel and inhuman society.”

To all those who live in pain from illness, disability, or old age, and those who care for them, Benedict encouraged them “not to lose their serenity, because nothing, not even death, can separate us from the love of Christ.”

Elenor K. Schoen is a writer and certified health care ethicist living in Shoreline, Washington.