Thursday, July 14, 2011

Is it Really Death With Dignity?

By Don Calbreath, PHD

On November 4, 2008, 58% of the voters in the state of Washington approved Initiative 1000 (1). This measure allows certain terminally ill patients to receive lethal medications in order to terminate their lives, thus making Washington the second U.S. state to approve a form of physician-assisted suicide. Thirty of the thirty-seven counties had a majority of votes in favor of the initiative, with a few mainly rural counties in the state not giving a "yes" majority vote (2). (. Although the state voters had rejected a similar measure in 1991 (54% voted "no"), the tide of public opinion has made a major shift in the intervening seventeen years.

Washington was not the first state to approve physician-assisted suicide - Oregon had already done so in 1994. But the history of physician-assisted suicide goes back even further in the U.S. Dr. Jack Kevorkian (known as "Dr. Death to many) had become interested in the issue of death early in his medical training in the 1950s (3). After a controversial and unsuccessful medical career, he became intrigued by medical reports of physician-assisted suicide in the Netherlands. Kevorkian became the leading U.S. advocate for this practice and contributed to the deaths of a number of individuals. His involvement ultimately led to him spending eight years in prison. Kevorkian died on June 3, 2011.

The movement in the Netherlands that had fascinated Kevorkian began in the early 1980s in that country, although Switzerland had allowed the practice since 1941. Even before the practice was legalized in 2002, Dutch physicians had administered euthanasia to approximately 2700 patients each year. The new law required that the patient request be voluntary and that the patient be informed about his/her condition and the alternatives.A second physician must be involved in the consultative process (4).

How well has this law worked out? Since it is very similar to the Washington and Oregon statutes, it is worth our while to ask what has happened since the enactment of this legislation. Not surprisingly, there have been flagrant abuses of the situation. There is growing awareness that the guidelines are often not followed and that many patients are euthanized without their consent (5). A number of patients felt that they were being pressured into the act. Of even more concern is the fact that at least one Dutch health minister suggested giving "suicide pills" to the elderly who are simply bored with their lives (6). More recently, she has expressed regret for her role in legalizing euthanasia in Holland (7).

Well, that's Europe, but things like that could never happen here. Let's take a quick look at Oregon, where "Death with Dignity" was made legal in 1994. One 2008 study showed that a fourth of the patients receiving lethal drugs were depressed, but were never referred to a mental health professional (8, 9). There are some indications that the law is not being followed with regard to proper documentation and review of requests. Perhaps the most troubling recent reports dealt with Oregon patients who were denied expensive medications for treatment of their terminal conditions, but were offered physician-assisted suicide instead (10).

Are there problems with the Washington law? One prominent Washington attorney pointed out several flaws (11). One of your heirs can be a witness to the consent form, opening the door to coercion. At the time of administration of the lethal dose, the patient does not have to have mental competency or even be aware that the dose is being given. A "self-administered" dose does not necessarily mean that - another person can give the drug, whether the patient is aware of what's happening or not. There is no requirement for witnesses at the death, leaving the door open for drug administration without the patient's consent or awareness.

Furthermore, the "official" cause of death will be listed as the underlying illness and the death is to be considered as "natural".So, it will be very difficult to investigate cases of murder under these conditions.

"Death with Dignity" was sold to the public under the guise of alleviating suffering in extreme cases and protecting patient autonomy. The reality is that abuses can and will occur, based on past experience with other statutes. Coercion will become more commonplace since there are few safeguards to protect against it.

Both the American Medical Association and the Washington State Medical Association oppose assisted suicide legislation as being inconsistent with the healing role of the physician (12,13).Outside the major population centers of Seattle, Tacoma and Olympia, many physicians and hospitals in the state of Washington will not participate in the practice (14).

One encouraging sign in this controversy is the increased awareness for better pain management and palliative care for terminal patients. Physician resistance to "death with dignity" statutes could lead to improved end-of-life care and a truly dignified death.





4. "Death with Dignity: The Dutch explore the limits of a patient's right to die", John Horgan, Scientific American, March 1991.

5. "The Dutch way of death", Rachel Nowak, New Scientist, June 20, 1992.



8. Oregon Death with Dignity program spurs fierce debate, intense criticism

Steve Maynard. McClatchy - Tribune Business News. Washington: Nov 9, 2008

9. "Death with dignity: The first decade of Oregon's physician-assisted death act", Heide Aungst, Geriatric, December 2008.


11. "Deatth with Dignity: What do we tell our clients?", Margaret Dore, Washington State Bar News, July 2009.



14. "In rural Washington state, law allows assisted suicide, but most doctors don't", Kim Murphy, LA Times, May 7, 2009.

*Don Calbreath PHD is the emeritus associate professor of chemistry at Whitworth University in Spokane.

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