Death With Dignity

The Prof, some friends and I had a lively debate the other night about I-1000, the “Death With Dignity” (a.k.a. physician-assisted suicide, or PAS) initiative being considered in Washington State this fall.

I was torn about it: my libertarian and progressive instincts both told me to support it (individual rights), but I’m conservative enough to be cautious about a potential radical social change like this. The radical changes I tend to support, like, say, universal health care and high-speed rail, are commonplace in nearly every other industrialized nation — which makes them a no-brainer in my mind. But PAS has a much shorter track record, and is legal in only a handful of places.

I realized that I didn’t know much about the law, or how it had been administered next door in Oregon, so I decided to do some research.

The Seattle Times lays out some facts about I-1000, modeled on Oregon’s law: the patient must have less than 6 months to live, two doctors have to certify that diagnosis and refer the patient to counseling if they suspect depression. Also, this is not euthanasia (which is legal in The Netherlands): the doctor can’t kill you. S/he can only prescribe a lethal dose of barbituates, which you have to be well enough to take on your own.

The State of Oregon’s Dept. of Human Services provides annual reports on the law, going back to its inception 10 years ago (Oregonians pased it 60%-40% in 1997). A few dozen doctors statewide write an average of 54 prescriptions each year, and of those, an average of 34 patients actually use the drugs to end their lives (see the 10-year summary, .pdf). The overwhelming majority are terminal cancer patients.

Out of our conversation came several potential objections to the law:

  1. Suicide should either be completely legal or illegal. It’s either right to kill yourself or it’s wrong, and this law is a half-baked compromise
  2. the diagnosis could be wrong
  3. It’s a “slippery slope”: Why not 7 months? Why not include non-terminal patients (as former Governer Booth Gardener wants to do)?
  4. Patients may be depressed.
  5. It elevates doctors to a new role in society, giving them the kind of authority that we usually limit to the legal system (this is why the Oregonian newspaper objects, though they admit that their concerns about safeguards were unfounded)
  6. Relatedly, doctors are potentially persuadable (“come on doc, I got 7 months, but can you just say it’s 6?”)
  7. It’s not a fundamental human right. “The right is life. Where does death fit in?” writes Joel Connelly.

I’m sure there are others. Something that the insurance industry is behind it, so they don’t have to pay for end-of-life care. But there’s no evidence of that, just insinuation, to my knowledge.

The first thing to note is that no law is perfect, and the perfect shouldn’t be the enemy of the good. I want universal health care, but I’ll settle for insuring every kid under 18. At least for now. Which gets us to the “slippery slope” argument. Could this law eventually lead to total legalization of sucide? I don’t know. But I do know that the great thing about democracy is that we’ll get to choose. Slippery slope arguments are used all the time, from gay marriage to gun laws. Liberalism itself is one, big slippery slope between the good of the many and the good of the individual.

Second, with respect to the doctors, I realized that what we’re talking about is not so different from “Do Not Resuscitate” or DNR laws, which I support. If you can tell a doctor that you don’t want to be hooked up to machines, why can’t you tell him/her you want a lethal dose of pills? And while I suppose the doctor is potentially corruptible (as in #5 and #6 above), we already assume the impartiality of doctors in so many other places in our society (say, with respect to diagnosing that a criminal is legally insane), is this really the one place to make an exception?

That gets to the fundamental challenge of this law, and how you view it. One way to view it is through the abortion lens, which is to say that it’s a personal choice, and the government shouldn’t get in the way. Dan Savage makes that argument in a very moving piece about the recent death of his mother. Another way to look at it, though, is as a natural societal adaptation in the face of advanced medical technology. We can prolong life artificially nowadays, sometimes nearly indefinitely. DNRs, which became popular in the 1960s with the first wave of defibrillators, were society’s way of adapting. Advanced cancer treatments can prolong life as well, sometimes equally painfully.

Finally, I can’t quite figure out how it hurts me if a terminally ill patient wants the option to end their life. I support public education and universal health care because it hurts me — economically, socially, etc. — when a poor kid can’t get a good education or health care. I support gay marriage, though, because it doesn’t hurt me at all if two people want to get married.

In general, suicide has negative externalities, negative costs to society: it hurts the ones you leave behind, it costs society money, public suicides (say over the Aurora Bridge) cause anguish to bystanders, etc. But I don’t think those negative costs really apply to the three dozen or so terminally cancer patients who want to go, in peace, at a time of their choosing.

I’m open to persuasion, but I think as of now I’m voting yes on I-1000.

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16 thoughts on “Death With Dignity”

  1. I am an attorney. I disagree that I-1000, supports “individual rights.” This is due to the lack of safeguards.

    Your list of problems with I-1000 leaves out that there is there is no requirement that the death be witnessed. See I-1000 (entire text). This creates the opportunity for a third party to administer the lethal dose to dad without his consent. Even if he struggled violently, who would know? I-1000 creates the perfect alibi.

    Family members often have their own agendas and may also financial interests that dovetail with a patient’s early death. I do not see it as a coincidence that the majority of patients who have used Oregon’s Act were “well educated” with private insurance. http://www.oregon.gov/DHS/ph/pas/docs/year10.pdf In other words, people with money.

    Was it really their “choice?” Vote “no” on I-1000.

    Margaret Dore
    Law Offices of Margaret K. Dore, P.S.
    http://www.margaretdore.com
    1001 4th Avenue, 44th Floor
    Seattle, WA 98154
    206 389 1754

  2. Margaret Dore is trying to make a name for her probate (wills) business by trolling against this initiative. She’s gotten more free advertising in this election than she ever got by just doing her job. There ought to be some sort of Bar rule against that, but regardless, she’s wrong.

    Your post is right on about I-1000. It should be up to the cancer patient themselves, not you or me or anyone else, whether they want to end their suffering. I’m voting YES on 1000 so that cancer patients can have that choice.

  3. Gloria’s post does not dispute my essential fact: I-1000 does not require a witness at the death itself. There is absolutely no oversight once the lethal dose is issued by the pharmacy.

    So you may sign up for the lethal dose thinking that it’s your choice. But the choice will really belong to the people around you–since no one is watching and they may have a financial interest to see you go (more money for them).

    Vote “No” on I-1000.

    Margaret Dore
    Law Offices of Margaret K. Dore, P.S.
    http://www.margaretdore.com
    1001 4th Avenue, 44th Floor
    Seattle, WA 98154
    206 389 1754

  4. I am an Oregon doctor. Your post asked how I-1000 can hurt you. It can hurt you by changing the delivery of your medical care. For a doctor, giving you a lethal dose will be easier than addressing your care needs, it will also be cheaper for your insurer. The safeguards are also ineffective so that you or a member of your family may be victimized. This is happening in Oregon.

    My own patient, who became depressed, was given assisted suicide. Instead of addressing his underlying problems, a colleague of mine simply gave him a lethal dose of a medication to end his life. Moreover, despite all the so-called “safeguards,” numerous instances of inappropriate selection, coercion, botched attempts and active euthanasia have been documented in the public record.

    This could happen to you or your family. The real tragedy of Oregon is that instead of doing the right thing, which is to provide excellent care, patients’ lives are being cut short by physicians who are not addressing the issues underlying patient suicidality at the end of life. This change in the direction of our profession, after 2,400 years of “Do No Harm,” concerns me. This should concern Washington residents as well.

    Don’t follow Oregon’s lead.

    Vote “No” on I-1000.

    Charles J. Bentz, MD, FACP
    Clinical Associate Professor of Medicine
    Division of General Medicine and Geriatrics
    Oregon Health & Sciences University
    Portland, Oregon

  5. Margaret Dore is right when she says, “since no one is watching and they may have a financial interest to see you go (more money for them.” Dr. Charles Bentz points to one of the many abuses in the slippery slope of physician-assisted suicide. Treating depression with assisted suicide is tragic. He is also correct when he says, “The real tragedy of Oregon is that instead of doing the right thing, which is to provide excellent care, patients’ lives are being cut short by physicians who are not addressing the issues underlying patient suicidality at the end of life.” The Oregon model is full of possible abuses, and can be a slippery slope, not allowing physicians to perform good medical care. Let’s not do this in Washington and in America.
    Wm. Reichel, M.D.
    Affiliated Scholar
    Center for Clinical Bioethics
    Georgetown University School of Medicine

  6. As someone that has known her for more than three years and has worked with her on several projects, I have nothing but the greatest admiration for Ms. Dore’s committment to the future of our elders and their fast-dwindling civil rights. To make this snarky comment that she is merely interested in her legal business shows that this person Gloria-something knows very little about her, and is speaking from frustration that our voices are not being drowned out by peddlers of this garbage. If she has taken an interest in this vitally important cause, you can blame me, and the dozens of other prominent Washington attorneys, doctors, nurses and advocates who have joined us in fighting against this initiative. Ms. Dore has not made a dime from her efforts and in fact has lost a lot of time and effort.

    The notion that I-1000 is only about “choice” is a hoax, and a prescription for disaster for underinsured Americans. Assisted suicide will change our country and our politics for the worse in big important ways, forever. And I fear that is just what the Yes-proponents desire.

    Oregon doctors complain there is already enough proof from the records leaking that the law is not at all functioning well as touted, and that the slope is already slipping under a shroud of secrecy, despite barriers to investigate and police it.
    Now, Washington’s law differs from Oregon’s in two big, important ways, making the shroud of secrecy all enveloping. In Washington, unlike Oregon, doctors will be REQUIRED to falsify death certificates listing the underlying illness as the cause of death rather than suicide, making it impossible to police whether the soothing protections are really working. Unlike Oregon, no witness is required, leaving the provision open to all sorts of deadly abuses. Once enacted, such absence of data could mislead legislators to future relaxations in protections.

    So, if the Oregon model were really working so well, why would its proponents need to shut off all information in Washington? I think I know.

    I refuse to let my right of “choice” to safe, quality medical care be infringed upon by others’ demands, tempting my hardworking-dedicated doctors with easy, cheap, legal, insurance-covered suicide.

  7. Okay, well, obviously my blog has been semi-hijacked by an anti-1000 action center of some sorts. That’s fine, I welcome the debate. Please keep it civil and respond to the arguments, though. I don’t really give a hoot about the integrity of Ms. Dore one way or another.

    The idea that this law will be a stalking horse for mass-murder of underinsured indigents seems like breathless hyperbole to me. Where’s the evidence for that happening in Oregon or elsewhere?

  8. Funny. I guess that google alert was wasted here, turns out Bruno is perfectly capable of making up his own mind – and capable of seeing for himself that the Oregon law has been safe and compassionate for over 10 years. Let’s hope the rest of the voters of Washington are so smart!

    Vote YES on 1000.

    http://www.itsmydecision.org

  9. The key issue remains that I-1000 does not require a witness at the death. This creates the opportunity for an heir, new “best friend” or stressed out caregiver to give the lethal dose to dad without his consent. Even if he struggled violently, who would know?

    This would not be a celebration of dad’s personal autonomy.

    Vote “no” on I-1000.

    Margaret Dore
    Law Offices of Margaret K. Dore, P.S.
    http://www.margaretdore.com
    1001 4th Avenue, 44th Floor
    Seattle, WA 98154
    206 389 1754

  10. Bruno,

    You asked about the insurance issue. Consider the case of Barbara Wagner. The Oregon Health plan refused to pay for a cancer drug to prolong her life, but did offer to pay for her assisted suicide. Unable to afford the cancer drug herself, she was steered towards suicide. This conduct, by an insurer, is illegal under current law (suggesting that the patient go kill herself).

    For further information. See: Rita Marker, Oregon’s Suicidal Approach to Health Care, American Thinker, September 14, 2008 at http://www.americanthinker.com/2008/09/oregons_suicidal_approach_to_h.html; Susan Donaldson James, Death Drugs Cause Uproar in Oregon, ABC News, August 6, 2008 at http://abcnews.go.com/Health/Story?id=5517492&page=2 and video of Barbara Wagner, at http://www.noassistedsuicide.com.

    Margaret Dore
    Law Offices of Margaret K. Dore, P.S.
    http://www.margaretdore.com
    1001 4th Avenue, 44th Floor
    Seattle, WA 98154
    206 389 1754

  11. Bruno, I disagree. I’ve studied the Oregon Act. The actions of the Oregon Health Plan were not illegal.

    Theresa Schrempp
    Attorney
    (No, I am not trolling for business, Gloria).

  12. Bruno, with all due respects, you said that, “I don’t see how that proves anything, except that the health plan acted illegally.” Can you cite any legal authority for that proposition? I can’t find one. What it proves is in fact the opposite, that there is no provision against it, and if it should be considered there should be.

    I think it proves a lot. There were a lot of Barbara Wagners that got that letter, but Barbara’s case got all the press. Lots of patients were denied care under the plan, probably because the law gave the state an excuse that made them comfortable with denying care.

    If the Wagner story proves anything, Ms. Wagner is a poster lady for the proposition, not only that Washington should again vote down I-1000, but that also Oregon should repeal theirs.

    This can only get worse. I wonder if the law would have any support if there were a provision in it that required state supported insurers to provide health care despite the availability of assisted suicide. Now that would be interesting, indeed!

    Why Oregon didn’t simply deny the claim entirely without offering suicide “benefits” instead as they have probably been doing for years totally ecapes me. That would have avoided the controversy, but they were too lame to even think of that. That was a moment of rare candor that I wonder if we will be treated to again.

  13. Bruno (and Gloria) what about no witness at the death? You don’t deny it.

    So someone could give the lethal dose to the patient without that person’s consent and no one would know the difference. The perfect alibi.

    And the other provisions that are a recipe for elder abuse? Sections 3 & 22 let your heir, a person who benefits from your death, take you to the doctor and witness the lethal dose request form. Section 1(3) lets that person talk for you.

    It will be your choice?

    Please.

    Margaret Dore
    Law Offices of Margaret K. Dore, P.S.
    http://www.margaretdore.com
    1001 4th Avenue, 44th Floor
    Seattle, WA 98154
    206 389 1754

  14. Keeping it to simplistic buzz-phrases:

    – Keep your laws off my (stiff) body.

    – No more Terry Schiavo-like government interference.

  15. This has nothing to do with Terry Schiavo. The issue is whether we pass an 18 page statute with fine print including that there is no oversight to protect you once the lethal dose is issued by the pharmacy.

    With no oversight, someone else can give it to you without your consent–and with the perfect alibi. How does that protect your “choice?”

    Margaret Dore

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