Exploring The Death With Dignity Act

Victoria Christensen

 

Physician-assisted suicide has become increasingly controversial over the past two decades.  Only eight states have legalized the practice, despite hard-fought campaigns in several other states to legalize it as well.  In 1994, Oregon voters approved the Death With Dignity Act (Ballot Measure 16) by a vote of 51% to 49%.  It became effective in 1998, surviving court challenges and a repeal effort, to make Oregon the first state in the country to legalize physician-assisted suicide.   The Oregon Death With Dignity Act allows an adult who is an Oregon resident and is suffering from a terminal disease that will cause death within six months, to terminate his or her life through the use of medication.  To do so, the person must express voluntarily his or her wish to die, must make a written request for the medication, and be found by the person’s attending physician and consulting physician to be suffering from a terminal disease.  The Death With Dignity Act is important for social work, particularly medical social work, because it directly affects an individual’s right to die, which in many ways contradicts the medical communities oath to keep people living as long as possible.  The DWDA enables qualified patients to avoid unnecessary suffering, to die with dignity, and to respect those patients’ right to autonomy or self-determination.  While there is no way I can address the complexity of this issue in this article, I will describe the social problems being addressed by the policy, discuss the history of the Act, provide a thorough description of the goals of the Policy and discuss the current status of the policy in Oregon.  

The Death With Dignity Act addresses the crucial social problem of allowing dying patients the right to control their own end of life care.   It is common knowledge that the aging population is increasing globally.   As a result, there is a pressing need for physician-assisted suicide across the globe; however, the notion of suicide stirs up a number of ethical issues about the choices people should or should not have with regard to death.  There are conflicting opinions by multiple groups; such as religious organizations, the medical community, and consumer groups.  Marjorie Zucker’s book The Right To Die Debate: A Documentary History (1999) examines the many voices in the debate and explores the controversy in depth.  In the introduction, she lays the foundation for the debate and explains why the ethical social problem has emerged in response to the way death in America has changed in conjunction with the progress of medical technology.

While modern medicine has made great technological strides in the Twentieth century to save and improve lives, physicians can and frequently use this technology to prolong the dying process.  She writes, “As physicians became increasingly adept at using developing technology and justifiably dependent upon it, they began to be uncomfortable with the notion that some patients ultimately could not be saved.  Medical professionals received a great deal of positive reinforcement for refusing to ‘give up,’ and many looked upon the death of a patient as a failure of their own” (Zucker, 1999, xxvi).  In response to the way death in America has changed, many health care professionals, lawyers, educators and members of the public began raising ethical and public policy questions; such as, when does the use of technology become overuse or abuse? When in the course of an individual’s illness should technology be focused on providing comfort rather than prolonging dying?

When is enough enough?   These questions have led to considerable controversy and a national conversation known as the right-to-die debate (Zucker, 1999).

The arguments in favor of a legal right to physician-assisted suicide are strong and varied.  The debate is often portrayed as a battle between social or religious conservatives who oppose the practice and liberals or progressives who support it. Those who support the Death With Dignity Act argue that death can be dreadful with high-tech medicine.  Patients who endure intolerable suffering ought to be able to end his/her life before her human capacities are irreparably damaged.  Furthermore, there ought to be a legal right to physician-assisted suicide in order to respect the patient’s moral right to autonomy and self determination.

There is research that has documented the most common reasons why someone might want to hasten their life. According to a report about DWDA by the Legislative Committee Services (June, 2010) “Physicians and families reported that patients have several reasons for requesting lethal medication.  These include concerns about losing autonomy, losing control of bodily functions, a decreasing ability to participate in activities that make life enjoyable, and physical suffering.  Also, many family members added that patients wanted to control the manner and time of their death” (p. 2).  

Assisted-suicide advocates often base their arguments on the moral conviction that each individual has an inherent right to determine his or her own destiny.  Thus, the right to life includes the right to end life, and it is as wrong to deny that right as it is to deprive a person of any other liberty.  They say that suicide is already legal in all states; only assistance in carrying it out is at issue (Zucker, 1999).  It is for these reasons and more that the terminally ill wish for a dignified death, and for these reasons that supporters of PAS wish to enable caregivers to provide it.

Death with Dignity is not only a legal issue, but a cultural and spiritual issue, too. Some faith traditions have embraced Death with Dignity as an ultimate act of compassion, and others reject it is as morally bankrupt practice.  Some opponents of legalizing physician-assisted suicide believe that intentionally causing the death of someone, even one who is dying, is morally unacceptable.  Sylvia Engdahl writes that “Most religions have traditionally held that all human life is sacred and that suicide is therefore immoral.  Christians believe that life is a gift from God so only God should determine when it should end; some of them believe that they would be punished in an afterlife for taking their own lives” (2009, pg. 65).

The main objection to the legalization of assisted suicide, apart from religious grounds, is that is may be a “slippery slope” issue.  In other words, one thing might lead to another—once a small concession is granted, the door is opened to larger ones. Opponents believe that such laws might extend to people who suffer from chronic illnesses or disabilities that are not terminal, but are costly and life debilitating—perhaps eventually even to the mentally ill.  Another argument is that if assisted suicide is legalized, sick people may be pressured into requesting it if they cannot afford medical care to relieve their suffering. Adrienne Asch, a noted bioethicist and authority on the rights of the disabled writes “Disability-rights activists fear that availability of assisted suicide will sway the public Into thinking that some people’s lives are not worth living, and that the ill and disabled may be led to feel that they have a duty to die rather than burden society with their care” (2005, p. 31). In other words, there is a fear that individuals disabled by a terminal illness would be discriminated against because Oregon law would no longer protect their lives in the same way it protects the lives of healthy Oregonians.

Opponents also argue that it is difficult to determine whether or not the patient has six months or less to live. In addition, there is a concern about the psycho-social condition of the dying patient. Daniel Callahan, M.D says that “the most common hazard of legalizing assisted suicide is the possibility that the patient is suffering from a clinical depression in the face of his or her illness and anticipated death.  Since depression is potentially treatable, a physician contemplating assisting in suicide must be very much aware of this possibility (1997, 71).  In other words, it is common for terminally ill patients to have some degree of depression, and that it is often difficult for some health care providers to detect as they don’t specialize in mental health issues.

            Prior to the Death With Dignity Act, there were no previous social policies that addressed assisted-suicide at the end of life.  However, prior to the 1950’s there was the beginnings of a Euthenasia Movement.  During the 1940’s the Euthanasia Society was formed with the intention to spread it’s message as widely as possible in speeches, on the radio, and in articles for magazines.   The society also wanted to promote legislation permitting voluntary euthanasia. Marjorie Zucker thoroughly documents the Euthenasia movement in her book The Right to Die Debate. She documents the impact of changes in medical care on end of life issues. The increased ability to maintain the life of mortally ill patients created a dilemma for physicians:  When, if ever, should they stop treatment?  While Euthanasia was highly controversial, medical professionals and educators realized the need for continued education.  Marjorie writes:

During the period 1953-65, the Euthanasia Society of America functioned as an educational organization, providing speakers to organizational meetings and on the radio.  No further attempts were made to pass legislation in this field.  However, the increased ability to maintain life in mortally ill patients provided a new impetus to the discussion of euthanasia.  Two influential books published in the mid-1950’s contained chapters on euthanasia.  One of these books was entitled Morals and Medicine, by Joseph Fletcher, professor of pastoral theology and Christian ethics at the Episcopal Theological School in Cambridge, Massachusettes, who was in favor of voluntary euthanasia (1999, pg. 64).

            As medicine became more advanced and increased peoples’ life spans, most were living to a reasonably healthy and comfortable age.  But for some, life became miserable, and for patients who were unconscious, it became meaningless.  As a result, the wish to control one’s fate, especially when one could no longer speak for oneself, led to the development of living wills or advance directives, or, documents that leave instructions for one’s treatment.  A man by the name of Luis Kutner, a Chicago human rights lawyer who promoted his strong beliefs in human rights in several ways, conceived the “living will,” a term that he coined.  A living will is a document that states one’s wishes about medical treatment at the end of life if one is unable to communicate them directly. Supposedly Kutner spoke at a meeting organized by the Euthanasia Society of America in 1967 and they drew up a living will in response to his proposal and distributed a quarter of a million copies to various medical professionals (Zucker, 1999). 

The Act began as a citizen initiative petition in 1994.  Ballot Measure 16 was approved by voters by a 51 to 49 percent margin in 1994. Despite the measures passage, implementation was tied up in the courts for several years. A legal injunction delayed initial implementation of the Act until October 27, 1997, when the Ninth Circuit Court of Appeals lifted the injunction. The 1995 Legislative Assembly referred Ballot Measure 51 (authorized by House Bill 2954) to voters on the November 1997 ballot, which would have repealed the Death with Dignity Act. Oregon voters chose to retain the Act by a margin of 60 percent to 40 percent. (Oregon Legislative Policy and Research Office, 1997)

Oregon and Washington are the only two states in the union that allow physician-assisted suicide. However, there is a long term goal to assist other states with the implementation of the policy. According to the Death With Dignity National Center Website, there has been a growing support of the Movement:

 With the 14 years of data showing Oregon's Death with Dignity law is safe and utilized the way it was intended with no evidence of a slippery slope for vulnerable Oregonians and since our win in Washington in 2008, bills which seek to improve end-of-life care have been introduced in state legislatures around the country.

State legislators have the Oregon and Washington laws to use as a guide. While many bills are drafted each year, the majority fail. Some consider it a failure that most bills do not end up becoming law, but we view these bills as a testament to the growing support of the Death with Dignity movement, the will of the public, and the strength of Oregon's and Washington's model legislation.

 Measure 16 is regarded as one of the most controversial ballot measures in Oregon’s history. As a result, various agencies are required to do long term research studies that document the progress and issues that arise.  The Oregon Health Division is required to annually review a sample of medical records of patients who requested a life-ending prescription.  In addition, they generate and make available to the public an annual statistical report of information collected under the Act.

The status of the policy in Oregon is good.  Oregon Public Health Division released it’s annual report for 2011, which reflects statistics from the 14th year of implementation, and encompasses data from January 7, 2011- February 29, 2012.  Peg Sandeen, MSW and policy advocate of the Death With Dignity National Center provides a concise summary of the report:

Consistent with information from prior years, the data show Death with Dignity is a rarely used option for a small number of terminally ill Oregonians. The report indicates the process was implemented, in every instance, under the strict guidelines written into Oregon law and the established medical standard of care that has evolved since implementation.

 

During the 13 months covered by the report, 114 qualified patients received a prescription under the provisions of the law. Approximately 62%, or 71 terminally ill individuals, died as a result of ingesting medication prescribed under the Oregon Death with Dignity Act. Sixty-two different physicians wrote prescriptions under the law. According to the Health Division's report, in the 14 year history of implementation, 935 prescriptions have been written and 596 individuals have ingested medication and died using the standards spelled out in Oregon law.

 

Similar to prior years, most of the qualified patients who used the medication to hasten death were over 65, had a terminal diagnosis of cancer, and received palliative care service through hospice. Additionally, participants tended to be well-educated (48% with a four year degree or more), had access to some form of insurance (96% with public or private insurance), and died at home (94%). The most commonly reported end-of-life concerns were: less able to engage in activities making life enjoyable (90%), losing autonomy (88.7%), and loss of dignity (74.6%) (2012).

 

It is important to note that the use of the term “Assisted Suicide” has been called into question by the American Public Health Association as it has negative connotations.

While “physician-assisted suicide” is an accurate and descriptive term, it should be replaced with the advocacy-phrase “aid in dying.”   Activists needed to make an attempt to redefine the crime of assisted suicide as a legitimate “medical treatment.”  Rita L Marker, an attorney and executive director of the International Task Force on Euthenasia and Assisted Suicide revealed that the term has negatively affected the Assisted Suicide Movement.  She writes, “In the more than ten years since the passage of the Oregon law, state after state has considered legalizing assisted suicide.  Each time, there was early support for the measure.  Yet, in each instance, when the official vote was taken, support had evaporated and the proposal went down in defeat” (2009, p. 121). 

As a result, assisted suicide proponents, particularly Compassion and Choices, searched for some way to improve their position.  Thus, they commissioned research and polling.  They found that people have a negative impression of the term “assisted suicide,” but, if euphemistic slogans like “death with dignity” or “end of life choices” were used to describe the same action, response was relatively positive. They embarked on a mission to replace it with kinder, gentler language.   In addition, they wrote press releases to the media, the state of Oregon and major public-policy organizations claiming that use of the term “assisted suicide” demonstrated insensitivity to dying patients and to the physicians who assisted them (Marker, 2007).

 

 References:

 

Zucker, Marjorie. (1999).  The Right To Die Debate:  A Documentary History. Greenwood Press: London, pg. xxvi.

Taylor, Bill. (2010).  Oregon Death With Dignity Act, Legislative Committee Services Report, Salem, Oregon, June 2010, pg 2.

Engdahl, Sylvia. (2009).  Assisted Suicide: Current Contraversies, Greenhaven Press: MI, pg. 65.

Asch, Adrienne. (2005).  “Recognizing Death While Affirming Life,” Hastings Center Special Report, November-December, p. 31.

Callahan, Daniel. (1997).  “Self-Extinction: The Morality of the Helping Hand,” Chapter 3, in Robert F. Weir, ed., Physician-assisted Suicide, Bloomington: Indiana University Press, 71.

Long, Lori. (1997). Basics on Ballot Measure 51, Oregon Legislative Policy and Research Office Report, Salem, Oregon.

Sandeen, Peg. (2012). Oregon Death with Dignity 2011 Report. Death With Dignity National Center.  Retrieved from: http://www.deathwithdignity.org/2012/03/07/oregon-death-dignity-2011-report

Marker, Rita. (2007). “When Killing Yourself Isn’t Suicide,” National Review, March 5, 2007,pg. 121.