Oregon Death With Dignity Act

Oregon Death With Dignity Act

Policy Analysis

The Oregon Death with Dignity Act as has been said before can be analyzed in terms of David Gil's Policy Analysis Framework. (Gil, 1976, pp. 31-56) Gil's analysis framework consists of three main objectives: 1) issues constituting the focus of the policy, such as its nature, scope and theory, 2) the objectives, values and ideological orientation of the policy, underlying theories, target population and the manner in which it is effected, as well as the financial costs and benefits, quality of life, historical background of the policy, the size, resources and values of the group supporting the policy, and 3) alternatives to the policy. (Gil, 1992) the policy analysis is an essential aspect of understanding with regard to any moral or ethical issue that potentially has a significant impact on the public. There is a clear sense that the right to end one's own life, as a cultural ideology has evolved, just as many other social issues have. In many ways there is a sense that the nation and individual states attempt to legislate morality with such acts, but in truth the Oregon Death With Dignity Act is an affirmation of self-determination, rather than a restriction of options, that frequently go under fire with regard to the legislation of morality. A policy analysis is a first step in understanding the whole of the issue.

Though a policy analysis is a substantial informative tool in a greater understanding of any given social or legal policy, in this case the analysis is indicative of raising more questions than it answers. The policy of the Oregon "Death With Dignity" Act is illuminated and better understood, though it is also followed with ideological ethical/moral dilemmas and concerns surrounding it. Including those specific to the policy, such as the fear of Oregon, becoming a destination for death or those specific to ideology surrounding suicide and/or euthanasia, like the fear that trying to prevent suicide is counter intuitive to passing laws that legalize it and reduce culpability of anyone who participates in it, if they do so within the guidelines of the law. In short Gil's policy analysis framework will serve both purposes, to illuminate the policy and ask important social questions surrounding it.

Like prior reformers who successfully argued and mobilized for changes in abortion, gambling, or marijuana laws, the proponents of euthanasia legal reform have argued that the use of morphine at the end of life is a form of de facto decriminalization of assisted suicide. Under the "double-effect" theory, doctors are not considered to have acted unethically-nor are they subject to criminal prosecution-if they prescribe or administer potentially lethal levels of drugs with the intent to ease pain, not cause death. Activist physicians like Quill aim to bring secret practices into the open-employing a classic argument for the change of a de facto practice to a de jure legalized or decriminalized practice. In the words of a New York Times editorial, it is only a matter of sanctioning what already happens with "wink and a nod" ("Assisted Suicide and the Law" 1997:A12). As we describe in Chapter 6, even Congress's Pain Relief Promotion Act of 1999, which undermines Oregon's assisted suicide law, sanctions the principle of double effect. To date, the authority to define this distinction between killing and letting die has been kept within the boundaries of the medical profession. This is what sociologists of law mean when they refer to the "medicalized" approach, and the medicalized approach to laws regulating hastened death are very much a parallel to abortion law before Roe v. Wade (1973). (Hillyard & Dombrink, 2001, p. 22)

The foundational debate will likely continue and this work is a demonstrative example of a clear policy analysis that details many of the issues that surround the Oregon Death With Dignity Act and the overall assisted suicide and/or euthanasia movements. It is not unusual for many ethical and moral issues to achieve success in the United States through progressive legalization and in the case of healthcare through medicalization. This emphasis has both positive and negative effects that will remain a part of the fabric of any civil rights action for the whole of the existence of the United States.

Focus of the Policy, Nature, Scope and Theory

In an analysis guided by Gil's Policy Analysis Framework, the "focus" of Oregon's Death with Dignity Act is to settle the inherent potential dispute as to what the desires of a terminally ill person really are. The nature of the theory is to eradicate the questions that frequently surround prolonged periods of terminal illness, prior to the event that the terminally ill individual cannot speak for him or herself and therefore lingers past the point of what is to them considered dignified. The goal is to examine, through a structured process what an incapacitated person truly wants in their current state rather than relying upon others to decide for them. Options are limited as they must choose either to live in their current state of potentially intractable pain and lingering terminal illness, or die with the aid of anaesthetizing medication, but prior to the enactment of this law in Oregon all parties were given only the first option, as legal. The second option was not a legal option and therefore if an individual chose to end their life prematurely their choice was limited to their own ability to commit suicide, through means other than medication, and without the assistance of anyone, including loved ones or a physician. Prior to this legitimization of physician-assisted suicide there was a situation associated with prosecution of any individual who knowingly assisted in the premature death of anyone, including a terminally ill person. Euthanasia is defined in contrast to physician-assisted suicide in that Euthanasia is generally thought of as the active administration of lethal means, or what some call mercy killing. In the case of Oregon's laws, as will be seen later physician-assisted suicide deems only that the physician provide the means for death, such as an overdose of medication, not be present or give the lethal medication, in fact administration is still considered illegal. Not to be confused sometimes the removal or denial of medical care or supportive care that is known to likely cause death is titled passive euthanasia. Physician-assisted suicide stands squarely in the middle, as the physician is knowingly prescribing medication that is taken will cause death, but is not administering the medication him or herself.

Suicide is frequently a drastic measure and can be associated with prolonged periods of grief as well as significant implications of for lack of a better term, clean up, in both a psychological and physical sense, for those left behind. (Mishara, 1995, p. 19) Proponents of the Oregon law contend that if people are allowed to commit suicide, under the described legal conditions this will lesson the event of violent suicides, that frequently occur, and especially among the elderly. (Marker, 2006) the scope of the Oregon policy is to remove responsibility of care and decision from someone other than the person actually living the experience of terminal illness, and reassert the rights of the individual to make his or her own life and death decisions. In one case in 1992 the following was a portion of the legal brief. This legal brief can serve as a solid example of the intentions of the law, not only is it to allow and individual to make ultimate life and death decisions for him or herself but also it is an attempt to reduce or eliminate legal responsibility for those who participate, including health care professionals and/or loved ones. The bid in Washington State to enact laws surrounding this brief has thus far become unsuccessful.

The patient plaintiffs made two claims: first, that they had a right to seek a physician's assistance with suicide without undue government interference, and second, that Washington's ban against assisted suicide unconstitutionally discriminated between assisted suicide and withholding or terminating lifesaving medical treatment. Plaintiffs from the Compassion organization claimed that the law put their staff members in jeopardy of criminal prosecution for assisting dying persons as they exercise their constitutional rights of choice in the face of imminent death. The physician plaintiffs alleged claims on behalf of their own patients, as well as on behalf of their own right to practice medicine according to their own consciences and professional judgments. (Hillyard & Dombrink, 2001, p. 126)

The scope of the Oregon law does not transfer to other individuals, such as those who might have vested interests in the termination of an individual's life. The scope is specific to the individual terminally ill patient, though there is a clear indication that others are affected by the decision the scope of the policy is to allow the individual, through a process to determine the desire, in a legal sense to die with the aide of anesthetizing medication. The laws text is as follows:

1) the patient must make two oral requests to the attending physician, separated by at least 15 days; 2) the patient must provide a written request to the attending physician, signed in the presence of two witnesses, at least one of whom is not related to the patient; 3) the attending physician and a consulting physician must confirm the patient's diagnosis and prognosis; 4) the attending physician and a consulting physician must determine whether the patient is capable of making and communicating health care decisions for him/herself; 5) if either physician believes the patient's judgment is impaired by a psychiatric or psychological disorder (such as depression), the patient must be referred for a psychological examination; 6) the attending physician must inform the patient of feasible alternatives to the Act including comfort care, hospice care, and pain control; 7) the attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. A patient can rescind a request at any time and in any manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate. (Oregon "Death With Dignity" FAQ)

Additionally, there are reporting requirements, on the part of the physician. The state has consciously set about to track the utilization of the law and make adjustments accordingly. "Physicians must report all prescriptions for lethal medications to the Department of Human Services, Vital Records. As of 1999, pharmacists must be informed of the prescribed medication's ultimate use." (Oregon "Death With Dignity" FAQ)

The individual, physician and witnesses must contest that the patient must not appear to be suffering from any psychological disorder that would impair his or her judgment or decision making processes. The criteria that an individual must meet to participate in the act are as follows:

The law states that, in order to participate, a patient must be: 1) 18 years of age or older, 2) a resident of Oregon, 3) capable of making and communicating health care decisions for him/herself, and 4) diagnosed with a terminal illness that will lead to death within six (6) months. It is up to the attending physician to determine whether these criteria have been met. (Oregon "Death With Dignity" FAQ)

Functionally, though some would argue not ideologically the theory behind the signing of "Death With Dignity" documentation is similar to signing advanced directives, in the form of what most institutions and professionals would call a "no code," where the individual, or his or her signatory signs a document that asks that no advanced measures be taken to extend the life of the individual. In a sense the legalese is much the same and guised along the same lines as a last will and testament that requires complete lucidity or a signatory who is aware of the individual's wishes. This is not in the least an unknown concept, that attempts to circumvent traditional legal documentation, the difference is that the precedence of the act of signing one's life away, not in a passive but instead in an active sense is at stake. This is to some theorists very similar to Roe v Wade (1973) (Hillyard & Dombrink, 2001, p. 125) with the exception that the individual is choosing to end his or her own life, and the "victim" is not nameless, faceless and voiceless, as many argue in the case of abortion rights. The individual has for all intents and purposes lived the whole scope of ones life, as they must be above the age of 18 to participate in the act. Though argument could also enter that the age of consent for most other legal responsibilities, 18 is far to young for participation in such a decision, legal precedence allows such. Finally, the state of Oregon also tried to limit their place as a destination for death by limiting availability of services to Oregon residents, (Hillyard & Dombrink, 2001, p. 69) though many are quick to point out that there is no formal residency requirement (such as in the case of other residency issues that hold time limits from 3 months to 1 year depending on the issue and state) one must simply prove that they currently reside in Oregon. (Oregon "Death With Dignity" FAQ) No doubt if abuses are noted through tracking (done yearly by the Department of Human Services of Oregon, as reported by physicians) there will be further stipulations placed upon those qualified to participate.

The clear purpose or focus of the law, to allow the individual dying patients the right to choose an early termination of their life, with the assistance of medication and a physician to prescribe it can also be muddied by situations where court appointed and statutory guardians have had potential conflicts of interest, and another party with authority, such as a doctor who is qualified by the law to determine whether the patient is terminally ill is needed to assist in settling the dispute. This is clearly an aspect of the benchmark act passed by Oregon, as many individuals and physicians choose not to participate for reasons that have little if anything to do with the actual desire to spare themselves or their loved one the agony of their dying days. Though in Oregon the stipulation was made that the physician, and/or health care provider was not the administering agent of the lethal medication, (a variance from California and Washington State legislative attempts) and that the patient must do so him or herself, legal implications are still present as the physician and by virtue of necessity the pharmacist becomes the avenue for the lethal medication. There are still many issues at work her that will likely be played out in the courts and legislatures for some time to come.

Objectives, Values, Ideological Orientation of the Policy: Underlying Theories, Target Population and the Manner it is effected, Financial Costs and Benefits, Quality of life, Historical background of the Policy

The values and the ideological orientation of the statute appear to be based on non-discrimination, civil rights and self-determination. Studies of patient attitudes toward assisted suicide and euthanasia indicate a patient's interest in physician-assisted suicide appears to be a function of psychological stress and social factors. Worldwide, about a million people commit suicide annually and the Surgeon General of the United States is currently campaigning to reduce this rate. "An estimated 765,000 Americans attempt suicide each year, according to the AAS [American Association of Suicidology]." (Wetzstein, 2000, p. 2) Though of these individuals only part are successful, more women than men attempt suicide but more men are successful and certain demographics of individuals are at higher risk, including but not limited to the elderly. There are few statistics that detail the reason for suicide, but it is to be assumed that many are cases of perceived terminal illness. The national and international attempts to prevent suicide are longstanding, though they have evolved over the years, ideologically altering the idea of suicide as an unforgivable act to one that needs to be treated with preventative measures. (Wetzstein, 2000, p. 2) it would seem that the acceptance of the right to die would be incongruent with the overall standard of attempting to reduce suicide rates. The results of a 2006 Gallup poll gives an indication of the overall ethical moral opinions on the issue of suicide:

Gallop Poll Question 1: "Next, I'm going to read you a list of issues. Regardless of whether or not you think it should be legal, please tell me whether you personally believe that in general it is morally acceptable or morally wrong? How about... suicide?"

Gallop Poll Question 2: Next, I'm going to read you a list of issues. Regardless of whether or not you think it should be legal, please tell me whether you personally believe that in general it is morally acceptable or morally wrong? How about... doctor-assisted suicide? (Public Agenda 2006)

The moral dilemma is of coarse vast and ethically sensational, but it holds true that civil rights and individual rights are an equally pressing part of the ethical/moral equation as are personal feelings regarding the fear many people feel when they attempt to empathize with individuals who are terminally ill or suffering and without the personal control to contain such suffering or even watching someone they love suffer, without the personal control to contain such suffering. Most individuals over the age of 30 have had at least some impact from the death of loved ones, and have watched as others struggled with decisions regarding the lives of others. In fact in a Time Magazine Poll (2005) there is a clear indication that at least one third of American's have had to make life or death health care decisions for loved ones.

Time magazine poll Question: Have you personally been in a situation with a parent or other loved one in which you had to make a choice about using extraordinary measures to keep them alive?

In a 2005 Pew Research Poll many people also intoned that they desired a stop of treatment if they were ever injured or ill to such a degree that they would not recover, or would end in their total dependence upon family.

Pew Poll Question: If you had an illness that made you totally dependent on a family member or other person for all of your care, would you tell your doctor to do everything possible to save your life, or would you tell your doctor to stop treatment so you could die?

There are few exceptions, as many people tone in on the desire to be able to make such decisions for themselves. So, even though it would seem incongruent to condemn suicide and support physician-assisted suicide. It is assumptive on any level to believe that such an issue as the right to end one's life, rather than endure seemingly unendurable suffering would be in the least bit a clear cut, black and white issue. Ultimately the issue is a civil rights issue, not unlike the utilization of the death penalty, the right to choose abortion legally or any number of other issues. The public holds many opinions and therefore demands many alternatives.

The underlying theory of the Oregon law is that an incapacitated or terminally ill individual should be given an opportunity to die with dignity, before becoming a burden on family and friends that take care of them. This theory is based largely on the assumption that terminally ill patients want to end their lives legally, rather than live in a state of incapacitation. According to some arguments society has not done much to educate the healthy population about the ways in which incapacitated or terminally ill people may live normal and dignified lives. There are also many who would argue that the United States in particular is a death denying society, in the sense that death is largely an isolated and institutionalized phenomena that many people are not exposed to until their own demise, or at the very least the demise of loved ones. (Heinz, 1999, p. 6) Though the hospice movement has come out, for the most part, strongly against active euthanasia the ideology of hospice needs to play an important role in the discussions of terminal illness, options and rights. The Hospice ideology contends that the individual has the right to die a natural death in the comfort of home and family, rejecting the institutionalized surroundings of the hospital or nursing home, unless such is necessary. To Hospice practitioners, death with dignity is possible, without its hastening and many aspects of it are healing to loved one, as they are given the opportunity to communicate with and help the terminally ill person cope with the passing of their lives. In turn the terminally ill patient can be given the highest level of palliative care possible to allow them to pass with as little pain and/or anguish as possible.

The movement embodies central concerns of the death and dying movement. A rigid medical model of dying is challenged; caring replaces curing as a fundamental treatment modality. Pain management medications that preserve alertness for a death of one's own but end the cycle of fear and acute pain are pioneered. Holistic approaches to patient and family dominate. (Heinz, 1999, p. 23)

The foundations of the hospice movement are those that reject the highly clinical assurance of medical care as capable of forestalling or even eliminating death, even in the face of the fact that most people logically know that life, by its very virtue will end in death. There are many movements that reject the idea that medical care should, at all costs reject the possibility of death and work without fail to save lives, even when that means a reduction of quality of life that is so extreme the individual might not choose it for him or herself or in a case where the cost of such care leaves such a burden on loved one and the individual that they will never be able to repay it and it therefore potentially creates a life not worth living. Traditional medical care has been fighting this fight since the legalization of the medical care system in the U.S. And continues to do so, now as it moves toward a partnership frequently called complementary care. (Starr, 1982, p. 47)

The underlying theory of the "Death With Dignity" act is that certain individuals afflicted with terminal illnesses should have the legal right to hasten their death.

As a result, individuals that acquire these disabilities and face a lingering and perhaps painful future may have the opportunity to view death as a viable alternative. Euthanasia and assisted suicide are not private acts but involve one person facilitating the death of another. This is a matter of public concern, since it can lead to tremendous abuse, exploitation and erosion of care for the most vulnerable. (Marker, 2006) the care that was taken by the framers of the Oregon law will likely continue to be assessed and affirmed as well as strengthened to ensure the safety of the most vulnerable of peoples. Yet, like anything else abuses will likely occur and choices will in a few cases not be made with the best intentions or for the most altruistic reasons.

The danger of defining "terminal" with time limits or definitions of illness is that different doctors may define these limits differently. In the Netherlands "terminal" is simply "concrete expectancy of death" and time limits and definitions of "terminal illness" have been fastidiously avoided, to protect both the ill and their physicians when a terminal illness or mental state cannot be judged within these limits. Patients may suffer long past the six months that the doctor assumes is remaining for the patient. (Marker, 2006) in Oregon, the legal interpretation of "terminal disease" is "an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months." [1995 c.3 s.1.01; 1999 c.423 s.1] ("Oregon Death With Dignity Legal Statute" Definitions, (12)

For the purpose of analysis and regardless of moral/ethical concerns that are raised by the determination of a time limit on length of life one has in order to be considered terminal, a consistent precedence has been set in the U.S. that 6 months, based on the knowledge and assessment of the physician and it is a standard time frame for many other legal and insurance determinations. There are clear indications of states and authorities wishing to change such a determination to allow patients with chronic debilitating diseases and a known limited life expectancy to receive care, such as hospice more easily. One can see from the Michigan Bill 781 and 782 which allow for the alteration of documentation to read "patient with reduced life expectancy due to advanced illness" rather than "terminally ill." The bill analysis also makes clear that the federal statute definition for terminal illness is a person with a life expectancy of less than six months, and this is the qualifying factor for the receiving of Hospice benefits through Medicaid or Medicare. (Michigan 2001) in a sense the statement is that the definition of terminal illness needs to be broadened but if individuals do not receive the diagnosis of terminal, by federal standards of a life expectancy of less than six months the care they receive, from a Hospice must be paid for by the patient, rather than by federally funded insurance agencies. This may seem an extreme obstacle, but in truth palliative care (presumably at home) may be far less costly than inpatient care in any institution, especially one where measures are being taken aggressively to prolong the end of life.

The target population that the Oregon Death with Dignity Act involves is those who are terminally ill and specifically the elderly, as this is the subgroup of the population that is most likely to me terminally ill. There are long and short-term effects of the law on the rest of the population, as well as the target population. It must also be said her that in a very real way, all individuals are mortal and so will at some time in their lives face issues of either their own death or that of others. The implication of this is that really the target population of the act is everyone. The manner in which the act is implemented and effects the immediate target population will likely affect not only this group but many others in the future. Oregon has the fourth highest rate of elder suicide in the United States, and the law appears to be a solution to a long-term problem. In a sense the state is saying that the elderly are committing suicide at high rates in Oregon, and should therefore be allowed to do so, under certain circumstances, which have been fully explored above within legal limits. A secondary target population is physicians and other health care workers who seek solutions for patients, who wish to end their own lives. The statute gives physicians the power to judge whether a particular suicide is rational and justified, based on the physician's evaluation of the individual's mental state. One short-term effect of the law is that personal, state and federal resources previously used to care for the elderly and terminally ill are freed up to be allocated for other uses. Since the law affects mainly the target population (those who are terminally ill), the public will find it difficult to take any actions that would change the minds of this small number of individuals. In studies of this issue, six out of ten Americans say they would consider ending their life if they were terminally ill. However, few say they are afraid to die and the majority of Americans believe suicide is morally wrong. (Public Agenda 2006) in either case, in Oregon their "right-to-die" will be supported.

The long-term effect of the Act is that no physician in Oregon will be charged with manslaughter or prosecuted under drug laws for facilitating an assisted suicide. Some fear that doctors will be in control of making all of the health care decisions for their patients, including whether they live or die. The Act has safeguards built in for this probability. The State of Oregon has a web site on the Death with Dignity Act. Those interested in more information may seek it out, as it summarizes the information collected on patients and physicians who have already participated in the Act. (Oregon 2006) Additional long-term effects of the policy set precedence for future legislation, potentially in other states, and this is supported with legal action taken by the supreme court in voting in favor of the Oregon law being upheld.

Many Americans say that people have a right to end their own life if they have an incurable illness or suffer great pain, but not because they have become a burden. (Public Agenda, 2006) in 63% of the assisted suicide deaths reported in Oregon, fear of being a burden was expressed as one of the reasons for requesting assisted suicide. (Oregon 2006) There is a clear sense that the financial burden that can be the legacy of an individual, with regard to chronic and/or prolonged terminal illness is a significant factor in the self-determination of the right to die. People not only feel as if they have the right to choose to die, if they are terminally ill, but also that they have the right to reduce the social and financial burden placed upon the family and/or society when they are terminally ill. The relative cost of care, for the terminally ill patient, who chooses to utilize the Act is minimal, as compared to the high cost of continuing to treat whatever disease or injury is creating the terminal state. Additionally, many people who are terminally ill have been so for some time and have gone through significant life saving procedures, that are frequently costly in many ways, but can be financially staggering. Frequently, if health coverage is minimal or non-existent individuals and families are placed in extreme duress, trying to pay for health care, some take out second mortgages on homes or even sell homes, sell all their assets and frequently require the kind of care that limits their own or their partner's ability to ear a living. Under this real life financial duress, it would not seem surprising that some of these people would choose to end their life than to continue to accrue debt that is not bringing them any closer to the goal of more quality time with their loved ones. The cost of utilizing the Act would be very minimal, likely ranging in cost from 200-500 dollars including the required physician's visits and the cost of filling a prescription. This of coarse does not address the cost of death, such as burial and other issues but such costs would have been accrued nonetheless. This is compared to an average cost of one day's stay in a hospital which depending on care can be in the range of 1,000's of dollars and the cost of the last few months of care in cases where life-saving tactics are utilized to the last moment which can range in the hundreds of thousands of dollars.

There are many groups and individuals who support the Oregon Death With Dignity Act. One of the groups supporting this law is comprised of doctors who see death from illness daily and prefer to allow decisions be made, in full disclosure of alternatives. The Initial 1990 attempt to create legal emphasis for the eventual Oregon Death With Dignity Act began in 1990, but was unsuccessful. Eventually the group moved toward public support eventually getting the measure on the ballot, for voters to decide in 1994, when it was first voted in and then again in 1997, when it was affirmed by the voters to an even larger degree. (Humphrey, 2006) in many ways the movement became a grass roots movement, to both achieve ballot choice and for its support and affirming legal battles. Not unlike almost every civil rights battle in the United States. Each movement makes slow progress toward universal acceptance, in both legal and cultural terms. As more and more people become aware of the divergence of need as well as possible options for any civil rights issue and more and more people alter their opinions based on public debate, laws and cultural acceptance change. In this case the idea that suicide is an unforgivable sin to the idea that it needs to be prevented in most cases and accepted as a viable alternative in others is an essential progression of a civil rights movement in the United States. Additionally, frequently such issues become accepted in one state and then, as success and debates continue more states begin to realign legal rulings with the new consciousness.

Other groups are made up of citizens desiring to lower health care costs, for the elderly and terminally ill population appear to be taking valuable health care resources from those who choose to live, rather than terminate their lives even if they choose to do so. Health care dollars will become an increasingly large issue in the future as the number of individuals who are living without health insurance increases almost daily and the fear associated with it is also increasing as more and more people become aware of what it feels like to live in this place of the unknown. With the reduction of health care coverage, in all populations the biggest fear of many people has become familiar with the fear that if they or a loved one were to become mortally ill the staggering costs of the care needed would likely leave many burdens behind. As health care reaches the pinnacle of this crisis, the need for public institutions to absorb the costs of the uninsured peoples will likely increase and further stress the system. A large portion of health care costs one accrues over a lifetime occur within the last days of their lives.

The distribution of health care costs is strongly age dependent, a phenomenon that takes on increasing relevance as the baby boom generation ages. After the first year of life, health care costs are lowest for children, rise slowly throughout adult life, and increase exponentially after age 50 (Meerding et al. 1998). Bradford and Max (1996) determined that annual costs for the elderly are approximately four to five times those of people in their early teens. Personal health expenditure also rises sharply with age within the Medicare population. The oldest group (85+) consumes three times as much health care per person as those 65-74, and twice as much as those 75-84 (Fuchs 1998). (Alemayehu & Warner, 2004, p.627)

The increase in the demographic of older people will also likely continue to place pressure on the system. With regard to those who are in favor of the Oregon Death With Dignity, many are aware of the statistics above as well as many other issues that are significant for the future of the culture, with regard to the manner in which we care for terminally ill people.