Policy Analysis of Oregon\'s Death

Policy Analysis of Oregon's Death With Dignity Act

David Gil's writings have helped the public understand the true scope of the new Oregon Assisted Suicide law, and as a result, the percentage of Americans who say that doctors should be allowed to help with suicide when the patient and the patient's family request it has doubled to 70%.

The fact that Oregon's law was a citizen's initiative that passed and other facts concerning physician-assisted suicides that have surfaced recently signal a renaissance of activism on the part of citizens who wish to change existing law on that topic. Even with the new Oregon law, it is not easy to participate, as there are requirements that make it difficult to obtain permission.

David Gil's Policy Analysis Framework has three main sections: (1) the issues of the nature, scope and theory behind the new policy focus; (2) the objectives, values and ideological orientation of the policy, such as theories, people it will affect and manner in which the law is used, including financial costs and benefits, quality of life, background, size, resources and values of group supporting it, and (3) alternatives to the policy. Following are the points he makes:

The analysis attempts to settle the dispute as to what the incapacitated person really wants: to live in their current state of pain and/or terminal illness, or die with the air of anesthetizing medications. This has been confused in the past by guardians of the patient with conflicting interests, and other parties with authority.

The values and ideological orientation of the law appear to be based on non-discrimination, civil rights and self-determination. Studies of groups wishing to utilize the law show that physician-assisted suicide may be a function of psychological stress and social factors. The underlying theory of the law is so terminally ill patients may be given an opportunity to die with dignity. This assumes that some people wish to die before becoming a burden or to die legally, rather than illegally.

The law allows individuals to the legal right to die, but this is not an individual thing to do. Another must be there to facilitate. So far, there have been no limitations on time and no definitions of "terminal illness" for those patients who participate, although 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.3s.1.01; 1999 c.423 s.1] (Definitions, 12)

The Oregon law not only affects those who are terminally ill, but has an effect on others, as well. Oregon has the fourth largest rate of elder suicide and this law may be a solution to a long-term problem in that state. Physicians can judge if a suicide is rational and justified. This may also have an effect on those considering suicide while they are terminally ill. In certain cases their right to die will be supported.

The law protects physicians in Oregon who may otherwise have been charged with manslaughter or prosecuted under drug laws for assisting suicide. Although this gives large leeway to doctors in their decision-making, the Oregon Death with Dignity Act has safeguards built in for this possibility.

The law does not allow people to end their lives for fear of being a burden to others, although this accounted for 63% of deaths from assisted suicide reported this being one of the reasons.

Doctors who daily see death from illness support this law, as well as citizens desiring to lower health care costs.

David Gil's Social Policy Framework includes an analysis of alternatives to the Oregon Death with Dignity statute. He claims the major alternative is to return to an environment where people suffering from terminal illness foresee a bleak future of suffering and long-term medical care unless they terminate their own lives illegally. But that they will not be taken advantage of by those simply wishing to do away with ill patients for any reason.

Review of Thesis by Debra Leeb

Debra Leeb says that "the law regarding the right of an individual to end his/her life has been affected both by advances in medical science and by shifting attitudes about individual rights and the rights and responsibilities of society." (Leeb, 1) She presents the viewpoint that, while the Oregon Act allows terminally ill patients with the ability to end their suffering legally, it devalues life and offends those with strong ethical beliefs.

The Oregon Death with Dignity Act allows one who is terminally ill who wishes to end their life to consult a physician and to make a written request for medication to end their life in a humane and dignified manner. They may choose their own manner of death now, but in the late '80s, initiatives to legalize such practices attempted to qualify in both Oregon and California, but failed (Purdy, 2006). Washington State attempted this in 1991 and California again in 1992, but these both were defeated. Oregon's law was passed in November of 1994 by a margin of 51%. An injunction delayed its implementation, but in 1997 the injunction was lifted by the United State Supreme Court, the Ninth Circuit Court of Appeals, and it became a legal option for terminally ill patients to obtain physician-assisted suicide. When a measure to repeal the law was placed on the ballot in 1997, Oregon voters upheld the law 60% - 40%. Other states have attempted to consider such legislation, but Oregon has been the only state to enact such a bill. Michigan and other states have enacted new laws making it clear that physician-assisted suicide is illegal. (Coueman, 2000)

The Living Will was conceived in 1967 by Luis Kutner. It authorized only the refusal of extraordinary measures in cases of advanced terminal illness. In 1990, Congress passed the Patient Self-Determination Act that allowed patients to specify if they wished to accept or refuse specific medical care. They could identify a legal representative for urgent healthcare decisions. The right-to-die movement advocates an automatic proxy statute that would give a designated person power to make decisions for an incompetent patient who never appointed a proxy or signed a living will.

Leeb discusses the circumstances that surround an end of life situation. This is usually something patients and their families have not talked about or prepared for. Medical practices make choices complicated, as "life" can be sustained medically through medical procedures. Whether this is helpful is not clear to those involved.

Leeb's study examines the Oregon Death With Dignity Act's origins and tries to identify shortcomings, the social and philosophical aspects of end-of-life decisions and make recommendations for amendments to the Act.

Leeb discusses the difficulty the Act had in becoming law, and additional attacks on its legality in the years that have followed its enactment. During the past 30 years, courts have consistently rejected attempts at legalizing physician-assisted suicide in California. The Karen Quinlan case beginning in 1975 in New Jersey, allowed a young woman in a coma to finally die in 1985. In this case the Supreme Court decided a patient's ability to have their life sustained by a respirator was up to them and their family, under the right to privacy (Annas). Subsequent judgments have cited individual freedom and privacy to justify decisions for incompetent patients who had never indicated their wishes in such matters. Life support can be terminated by close members of a family, employing the concept of substituted judgment. Substituted decision-making concerning respirators has since been enacted by New Jersey, Massachusetts and California. California also included the withdrawal of food and fluids.

A complicated case arose in California, when a terminally ill woman with cerebral palsy requested the right to starve herself to death in a hospital and the hospital refused, treating her for suicidal intent instead, force-feeding her. ACLU lawyers came to her defense, but a court upheld a denial of the patient's injunction against the hospital. She was subsequently released from the hospital because she no longer needed inpatient care (Cummins).

Also, in California, a 49-years-old injured man was disabled in 1993, both mentally and physically and depended on artificial feeding and hydration to survive. His wife requested the right to turn off his life support in 1995, saying he would not have wanted to live in this condition. However his mother and sister objected and a long fight ensued (Eisenberg, 2002,). The man died before the case was decided, but the California law was narrowed to cover only conscious patients who had left no formal directions for healthcare who would die without life support, but did not affect patients permanently unconscious, including those in a comatose or vegetative state, or those who had left legal instructions regarding healthcare or who had appointed another to make such decisions.

In 2003, Terri Schiavo, her husband and family faced a similar situation. Terri collapsed in 1990 at her home in Florida and had been in a coma since then, supported by feeding tubes. Emotions ran high throughout the United States during the highly publicized case, involving politicians and interest groups up to the United States Congress. In March of 2005, she was finally removed from life support and died thirteen days later. The case had 14 appeals, numerous motions, petitions and hearings in Florida courts, five suits in the Federal District Court; Florida legislation struck down by the Supreme Court of Florida; a subpoena by a congressional committee in an attempt to qualify Terri for witness protection; federal legislation and four denials of certiorari from the Supreme Court of Florida (Jacoby 2005). The courts continued to hold that Terri was in a permanent vegetative state (PVS), and an autopsy showed that most of Terri's brain had atrophied.

Leeb outlines the responsibility of social workers to be knowledgeable in policy and law concerning end of life decisions. Sensitivity to ethical and moral considerations is also urged. Cultural differences may be encountered in such situations, as well.

A final discussion of the Oregon Death With Dignity Act reminded the reader that the bill is important for having been passed by a majority of the voting public, and for giving terminally ill patients choices about whether they can end their life or not if they wish. The bill reflects the ambivalence of society on the subject of whether an individual has the right to control the time and manner of their death, and whether society needs to upheld sanctity of life at all times.

Dr. Jack Kevorkian

Dr. Jack Kevorkian is currently serving out a 10-25-year sentence for assisting the death of a terminally ill patient in Michigan. In 1987 he advertised in Detroit papers that he would help other ill patients to commit suicide, although he himself would not kill them. He subsequently assisted nearly 100 patients in voluntary euthanasia, by attaching them to a device that released drugs into the patient's system. The patients themselves pushed the button that allowed this to happen. He was hindered in his attempts by the medical profession that revoked his medical license after the first two deaths.

1990 article by Kevorkian was entitled "The Last Fearsome Taboo: Medical Aspects of Planned Death" appeared in Medicine and Law. In it, he argued that modern society, facing the longstanding prohibition against planned death, was "subjected to unrelenting paternalistic control based on moral codes that are rapidly becoming obsolete." He called the medical profession "physically (philosophically) retarded, drifting aimlessly without a coherent or even workable ethical code." It was Kevorkian's theory that the medical profession did not have an ethical code at all, but should because it should allow the death of those who suffer, rather than trying to keep them alive. (Betzold, 1993, p. 14)

In 1998 the broadcast of 60 Minutes featured a film of Kevorkian administering a lethal injection to Thomas Youk, an adult male with full decisional capacity in the final stages of ALS (Lou Gehrig's Disease) who had provided his fully-informed consent on the day of his death. Following the broadcast, the district attorney brought murder charges against Kevorkian, claiming he had single-handedly caused the death.

Kevorkian had been tried numerous times in Michigan for assisting in suicides, but had been acquitted before the Youk case. He had also gained public support for his cause. In this 1999 case involving the death of Youk, he was charged with second-degree homicide and for delivery of a controlled substance. He was not tried for assisted suicide, which was an area of law in flux, but for homicide, which is an area of law that is relatively fixed. During the trial, Kevorkian dismissed his attorneys and represented himself (pro se). The judge ordered a criminal defense attorney to remain available for information and advice, as Kevorkian encountered great difficulty in presenting evidence and arguments because of his inexperience with law.

The Michigan jury found him guilty as it was proven he had directly killed a person, as his patient was unable to do it himself because of his debilitating illness. On September 29, 2005, MSNBC aired an interview with Kevorkian indicating that if he was granted parole he will not resume directly helping people die and will restrict himself to campaigning for a change in the laws. He has been denied a parole and is seeking a pardon. Recently, an ABC interview with Kevorkian's lawyer revealed that Kevorkian is terminally ill with Hepatitis C, which he contracted during a blood transfusion and is expected to die within the year.

Ironically, in 1988, Dr. Kevorkian, in an interview with Michigan investigator, Svoboda, said he had planned to assist in a suicide when he was living in California but "there was an attempt to get euthanasia on the ballot and he was asked to refrain from performing the illegal act."

Continuing the interview, Kevorkian said, to qualify for his help in dying, a patient "would have to be terminally ill and would have to be met by the attending physician four or five times" and that "an attempt should be made to dissuade the person." Later in the interview, Svoboda noted "he said it should take only one meeting by a bioethicatrist. The second meeting could last five seconds but at least it would be in the records."

Svoboda noted that Kevorkian "fashions much of his thinking on the way these deaths are prepared for and done in Holland."

Dr. Kevorkian does not believe laws should rule or guide morality," Svoboda concluded. "Dr. Kevorkian maintains he is law-abiding but cannot agree or condone how law does not represent the consensus of society. He is making every effort to change laws and at the same time fulfill the demands of society. Dr. Kevorkian writes about his opinions -- he has not acted on them." (Betzold, 1993, p. 20)

The Federal Government and States Treat Physician-Assisted Suicide in the Courts

In 1997, the U.S. Supreme Court unanimously upheld decisions in New York and Washington State that affected assisted suicide and made it illegal. They overturned rulings in the 2nd and 9th Circuit Courts of Appeal striking down state statutes banning physician-assisted suicide. Those statutes, which prohibited doctors from prescribing lethal medication to competent, terminally ill adults, were found to violate the 14th Amendment. In striking the appellate decisions, the U.S. Supreme Court basically declared that no constitutional "right to die" existed, but individual states might enact legislation permitting or prohibiting physician-assisted suicide.

In April 1999, physician-assisted suicide was still illegal in almost all states. Over 30 states have statutes prohibiting assisted suicide, and a number of states that do not have statutes prohibit it through common law. Jack Kevorkian was initially charged with violating Michigan's state statute, as well as being charged with first-degree murder and violating drug laws for delivering a controlled substance without a license. However, when he was convicted of second degree murder and delivering a controlled substance without a license, the assisted suicide charge was dropped.

The only legislation addressing this issue on a federal level came in April of 1999 with the Assisted Suicide Funding Restriction Act. This 1999 Act prohibited federal money from being used to support physician-assisted suicide. In 1998, Henry Hyde (House Judiciary Chairman) and Senator Don Nickles introduced bills in the House and Senate to revoke the license of any doctor to prescribe federally controlled drugs if they participated in an assisted suicide. If such legislation had passed, doctors in any state, even those that legalized assisted suicide, such as Oregon, would have been subject to the federal sanction, though their actions were permitted under state law. (Law, 2005)

In June of 1997 (Vacco v. Quill and Washington v. Glucksberg) the Supreme Court found that there was no constitutional right to die with the help of a physician and upheld the state bans on assisted suicide. The vote was 9 to 0. At issue was whether assisted suicide is protected by the Constitution and whether criminal penalties for those who aid in assisted suicide violate the 14th Amendment's Due Process Clause. (Physician, p. E1)

Shortly after the Schiavo case, in 2001, there was a possibility that a ruling by the U.S. Supreme Court during its next term could effectively invalidate the controversial Oregon law known as the Death with Dignity Act, as U.S. Attorney General John Ashcroft brought a federal suit against the State of Oregon.

In February of 2005, the Court considered the legality of the Bush administration's effort to outlaw physician-assisted suicide in Oregon. The events leading to the death of Terri Schiavo had focused national attention on end-of-life decisions and the Court's acceptance of the case formerly known as Oregon v. Ashcroft reflected the public debate on assisted suicide. The justices heard oral arguments in the case, now known as Gonzales v. Oregon, in October of 2005.

A timeline of the case follows:

On November 6, 2001, Attorney General John Ashcroft issued a Directive stating that a doctor could lose his or her federal registration to prescribe controlled substances if that registration is used to prescribe federally controlled substances for assisted suicide.

On May 7, 2003, the Ninth Circuit Court of Appeals heard oral arguments in a case involving the Ashcroft Directive in court proceedings.

On May 26, 2004, in a 2-1 decision, the Ninth Circuit declared that Ashcroft overstepped his authority in issuing the Directive.

On July 12, 2004, the Justice Department petitioned the Ninth Circuit Court of Appeals to reconsider its May decision. The Court refused a rehearing.

On November 9, 2004, the Justice Department petitioned the U.S. Supreme Court to hear the case.

On February 22, 2005, the Court agreed to hear the case of Oregon v. Ashcroft. Oral arguments were heard on October 5, 2005.

On January 17, 2006, in a 6-3 decision, the Court held that the Controlled Substances Act (CSA) does not allow the Attorney General to prohibit doctors from prescribing federally controlled drugs for physician-assisted suicide in a state where the state law permits physician-assisted suicide.

Doctors Speak Their Mind on Physician-Assisted Suicide

Arthur Caplan, Ph.D., Director for the Center of Bioethics, Philadelphia, stated that he was in the camp of critics, worry warts and nay-sayers, worrying about whether those who had been assisted into death by a physician might have offered the best option that the system could afford. He wondered is there was someone out there who might have gotten some help, but feeling like he or she were at the end of their rope, knew of no other options. He stated that until America updates its insurance program so that there are options for those 40 million who cannot afford insured healthcare, assisted suicide remains the option of last resort and he will argue against it.

That would not be to say, he said, that individual cases may not warrant assistance, because he has seen cases where it was not immoral, but he fears that as a society, we are headed towards an old age with no healthcare and therefore more deaths. If an elderly or terminally ill person is allowed to live, society will be drawing down resources to help them, as they cannot afford it themselves, and have not been able to avoid it with the health coverage they have. Baby boomers, he predicted, are destined to put a huge strain on the system as they move into the elderly stage of life.

Caplan says that assisted suicide will not be the option of last resort for those suffering elderly who cannot afford palliative care, but the attractive first resort. He does not think the government will be dictating that someone should die because they are too expensive and "should do the responsible thing and leave," but the options will not be good, and assisted suicide arguments today will not ease the situation tomorrow without better healthcare.

What we have now, he says, is people who are saying "They won't stop giving me this technology, can't you disconnect it and let me go?" The incentive to help people to die to neutralize the financial issue is already here as the number of people affected is already becoming so large.

Caplan believes controlling death was the issue for Kevorkian. It is also the issue in the death-assisted suicide cases, as well as in the cases where physical human life is sustained for decades, even though there is no mental human life there and the patient is not allowed to die a natural death. The concept of "I'll control the timing of it. I'll beat death by becoming its master... frightens me.," he said. He believes that trying to control death is strong in American culture, that rather than giving in and being compliant, "we will master it." So, he says, we don't disconnect the machines. We take the dying out of our homes and put them into institutional settings. We can't talk about it either in theological terms or medical terms. (Caplan, 2005)

In a PBS interview, Dr. Timothy Quill expressed his views on assisted suicide. Quill is Professor of Medicine and Psychiatry at the University of Rochester School of Medicine and Dentistry, Rochester, New York. He is Primary Care Internist and Associate Chief of Medicine at Genesee Hospital and is a known expert in the field. He says that as far as assisted suicide is concerned, doctors have been doing this in secret, and now we are having to deal with the issue of good care for dying people, which is what all that good doctors want.

He says that people who are in terrible pain may try alternative medicines and drugs, but they always remember that there is "an out," which means that if their suffering becomes unbearable, they know they can choose to die. He said he had talked with patients about this and they had told him they were glad to know there was an alternative, though they didn't think they would every have to use it. As a matter of fact, he said, if they were receiving good hospice oriented care, they rarely want or have to use it. He said that people who have the choice of having their respirators turned off rarely use that option.

He gave the example of Elizabeth Bullier, who fought for the right to have her feeding tube stopped, and won her court battle. But then she chose to continue to live, because she had the key to escape, if she chose, and wasn't being forced to keep on living. The availability of a choice is very important. (Quill, 2005)

Scope of the Problem

From a marginal issue, the issue of physician-assisted suicide has become a topic of discussion for most people in the United States. These issues have become real, up-close events: real experiences happening to real people, and it is all to the good. The United States is moving toward this change in a relatively short period of time. Both Dr. Quill and others are uncomfortable with the rate of change in this field and Dr. Quill is not sure that there is going to be a net gain by affording physician-assisted suicide to the public. In the past it was secret, as doctors just turned their backs on suffering patients who wanted to die, having given them something to end it with. Studies have shown this is happening, but if it becomes an open practice there will be more dialogue with people, doctors and patients, and instead of a quick fix, maybe it will become just an option among others.

A study was done using doctors in the State of Washington which was a large survey of mainstream everyday physicians. The study showed that 16% of doctors in the year of study had a genuine request from at least one patient in the prior year for an assisted death and one quarter of those doctors had provided a lethal prescription. Almost none of the cases had a formal consultation of any kind. The transaction was secret and very rarely was the request simply from under-treated pain, but more of a combination of debilitating physical symptoms, plus extreme fatigue with living, loss of dignity, tired of being dependent, all of these in combination with severe physical symptoms. (Quill, 2005)

The two problems facing the medical profession and the American public are: First, promoting palliative care because it is impossible to tell whether those in secret cases actually received good care. The key is making sure all people get good palliative care first, to set a standard for care that everyone, rich or poor, should receive, and if this is done, a person may never come to the point of wishing to die. Assisted dying comes down to the desperate point when healthcare fails. Secondly, it should be subject to safeguards, such as having an independent second opinion after a diagnosis of terminal illness.

A doctor may not intentionally allow a patient to die, but if it happens unintentionally, and the doctor does not really mean to do it, it is all right. That is the way the standard is set up now. That is a violation of the medical code, because unless a doctor has a very convoluted way of thinking about what he or she is doing (you can do it if you do not intend it, but if you intend it, you can not do it), it is illegal. Doctors have developed even more complicated ways of thinking about and rationalizing their actions: The doctor foresees the consequence of a person dying as a result of what the doctor is going to do, but the doctor can not intend to do it.

The two main problems that arise from secret physician-assisted suicide are that there are no controls and there is no second opinion.

Question of Healthcare

There is no standard of care set up that will determine if the patient had good palliative (anesthetic or pain-killing) care. The standard of palliative care needs to be set up for everyone, and according to Drs. Quill and Caplan, if it is set up correctly, the need for physician-assisted suicide will decrease. The second standard that should be set up is to have a second opinion from someone who has had a lot of experience working with dying people. Dr. Kevorkian did not have any experience with dying people who chose to go on living, finding a way to survive and maybe even enjoying life, finding meaning in what they are doing. His experience was always at the moment of death, as his occupation was one who surveyed people just as they were dying and recording their bodily functions at that moment, which is only a small part of the whole picture. (Betzold, p. 45)

The rationale for giving chemotherapy is very similar to the rationale for allowing a terminally ill person to die. Chemo may produce nausea and vomiting and other bad symptoms and suffering, but the intention is to prolong life. A doctor is doing something similar for a patient who is at the end point of his illness. The doctor may prescribe higher and higher doses of pain medicines, which may suppress respirations, may make them more likely to die, but the possibility is there because the pain level is so high and the purpose is to relieve pain and suffering. When that person who is starting to suffer in an extreme way starts asking for help in dying, the doctor may not help them intentionally to die. In other words, the doctor must under-medicate because he or she cannot intentionally give enough medication to kill the patient, which is what is needed to relieve the pain and suffering at that particular point in the progression of the disease.

What the Kevorkian cases in the early 1990's showed doctors in the United States was that it is very difficult to prosecute a doctor for this kind of activity. According to Drs. Quill and Caplan, the Kevorkian cases did not help doctors figure out how to better help the dying. But he did bring the public's attention to the situation. Now there needs to be a public discussion on how better to care for the elderly and dying. Both doctors Caplan and Quill agree that doctors are not supposed to help people die, but to help people live. It will be a hard road to get the public to support that in a financial, physical way, with better healthcare for everyone. There does not need to be an group of people amongst us (though it may be a large group) that has to choose whether it is better to live or die because their healthcare is not making it very easy to live.

Doctors want people to feel better and live more meaningful lives. That means relieving suffering, helping to get them into hospice care and then doing the hard work of addressing symptoms, mobilizing support in terms of therapy and medications for quality of life.

But if a person still has a bad illness, with pain and suffering, doctors have an obligation to help the patient through that process. When the person starts to talk about wanting to die the doctor should find out why before responding to the emergency with either a suicide watch or by aiding the patient to commit suicide. If the doctor understands why the patient wants to kill him or herself, then there are responses to the reasons. If it is because they have reached the end of the rope, then the physician has a hard decision to make. Often, in these situations, the doctor is not qualified to make this decision, as an expert in psychology and psychiatric therapy may be called for, instead.

Great emotions and pain enter into these kinds of situations, when a person is really at the end of their rope. A doctor who has had experience with patients in terminal illness can see that there may come a point when there is nothing else to do. Talking to the person is not enough, though it is necessary. Doctors need to be trained how to talk to a dying person to determine if further psychiatric therapy is needed instead of medications.

Sometimes depression brings a person to the point of wanting to kill him or herself. Talking about the desire to kill oneself will determine if that is the case. If depression is the reason for the decision, then the person needs to see a psychiatrist.

But if a person is short of breath and needs medication to continue to breathe and asks to be given enough medication to die quickly rather than in, say, two months, then one can't say that the person is depressed, but is looking realistically at the process of dying. Still, they should see a psychiatrist to determine motivation.

Part of the standard of treatment for the elderly and terminally ill should be consultations with psychiatrists, as many of the problems facing a dying patient may be relieved through therapy, if it can not be relieved medically (Quill, 2005).

Do the Terminally Ill Really Want Physician-Assisted Suicide?

In a national survey of physicians about physician-assisted suicide and euthanasia in the United States, the New England Journal of Medicine found that from 1,902 questionnaires answered by 3,102 physicians in 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide, 11% said that, under current restraints, there were circumstances in which they would be willing to hasten a patient's death by prescribing medication, and 7% said that they would provide a lethal injection; 36% and 24%, respectively, said that they would do so if it were legal. Since entering practice, 18.3% of the physicians (320) reported having received a request from a patient for assistance with suicide and 11.1% (196) had received a request for a lethal injection. Sixteen percent of the physicians receiving such requests (42); 3.3% of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7% (59), said that they had administered at least one lethal injection. The conclusion was that a substantial portion of physicians in the United States in the specialties surveyed reported they received requests for physician-assisted suicide and euthanasia and around 6% complied with such requests at least once (Meier, et al., 1998).

In a study of 100 patients in Oregon and Washington with Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig's Disease), and 91 of their care givers, 56, or 56% of patients said they agreed that under some circumstances they would consider taking a prescription for a medicine whose sole purpose was to end their life. Furthermore, 44 or 44% agreed with a statement that said "If physician-assisted suicide were legal, I would request a lethal prescription from a physician." One patient stated they would have taken the medication immediately, but 36 said they would keep it for future use. Most of these were men, had a higher level of education, were less likely to be religious, had higher scores for hopelessness and rated their quality of life as lower.

Compared with these are the ones who agreed with the statement "I would never request or take a prescription for a medication whole sole purpose was to end my life," who were mostly women.

In 66 of 91 instances (73%), care givers and their patients had the same attitude toward assisted suicide. The article concluded that a majority of persons with ALS would consider physician-assisted suicide. Many would request a prescription for a lethal dose of medication well before they intended to use it. (Ganzini, 1998)

Gonzales v. Oregon discusses thoroughly the questions raised in the federal court. This was the case (discussed later) that determined whether the federal government could overrule a state in its legislation of controlled substances. Following this challenge, Oregon still had the authority to make it legal for doctors to use controlled substances in physician-assisted suicide, as the federal courts refused to overstep the state's authority.

Breakdown of Policy

Considering the facts as determined above, that physicians already practice secret physician-assisted suicide, there is a question as to whether there is rational basis for Oregon to immunize physicians from liability for actions taken in "good faith" irrespective of any medical community standard which applies to their actions. The fact is that it is irrelevant whether physicians act knowingly, or act secretly. The courts had already found that there is no set of facts under which it would be rational for terminally ill patients to receive a standard of care from their physicians under which it did not matter whether they acted reasonably, according to professional standards. This goes to the very heart of the state's reliance on a person's consent to die. The physician is allowed to negligently misdiagnose a person's condition and competency and negligently prescribe a drug overdose, so long as those actions are in "good faith." This distinction in the physician's standard of care is relieved and only made legal by the Oregon Death with Dignity Act.

Yet, there is no requirement that the person take the lethal overdose at the time of the prescription or under the supervision of a physician. It provides that the attending physician may prescribe drugs, but does not limit that prescription to drugs which have to be ingested. A prescription may be taken intravenously, or a physician may give the patient a device for releasing the drug by a switch or gas mask. These possibilities possibly subject a vulnerable person to potential abuse at the hands of others, and without the person's knowledge or consent. The Oregon Act does nothing to ensure that the decision to commit suicide is rationally and voluntarily made at the time of death. As a result, it purports to recognize a competent terminally ill person's choice to obtain the means to end their life should they commit suicide while competent, incompetent, or unduly influenced at some future time, including hours, days, weeks, or months later. A person decides when, where, and most important, whether to take the prescribed drug without any legal protection. On the other hand, the terminally ill patient may either wait to use the drugs when that patient feels they cannot go on because of unbearable pain, or they may choose to never use the choice at all and die naturally. Either way, the patient is the one making the decision. If others surrounding the person make that decision for the patient, they are liable for the murder of that person. The law is available for the use of patients who choose to use it and there is no pressure to do so.