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If the Washington act takes effect as scheduled on March 4, 2009, there will be two states in which physician-assisted suicide is legal; no states permit euthanasia. Physician involvement in hastening death is also legal in Belgium, the Netherlands, and Switzerland — the specifics vary by country — and is an underground practice elsewhere.
The prescription of lethal doses of medication to terminally ill people who want to hasten their own deaths is inherently controversial. The Washington State Medical Association opposed the initiative, and doctors have divergent views on the matter. In 1991, voters in Washington rejected a broader initiative that would have allowed doctors to administer the lethal drugs. The controversy carries over into disagreements over terminology; designations such as "death with dignity" and "physician-assisted suicide" may be considered emotionally charged and judgmental. Indeed, deaths under the Oregon act are not classified as suicides. Although some prefer terms such as "physician aid in dying" and "physician-assisted death," physician-assisted suicide remains a frequently used descriptor.
Amid the controversy and debate, the hastening of death by physicians under Oregon's act is uncommon. Between 1998 and 2007, physicians wrote a total of 541 prescriptions for lethal doses of medication (almost always secobarbital or pentobarbital), and 341 people died as a result of taking the medications (see graph). Thirteen patients who had received prescriptions were alive at the end of 2007, and the rest of those who received prescriptions ultimately died of their underlying disease. The group of patients who died after ingesting a lethal dose of medication had a median age of 69 years, almost all were white and relatively well-educated, and the group consisted of slightly more men than women, according to data collected by the Oregon Department of Human Services. About 86% were enrolled in hospice programs, and 81.5% had terminal cancers.
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Because of the nature of their medical practices or personal objections to involvement, most physicians in Oregon have never written a prescription for a lethal dose of medication; in 2007, 45 physicians wrote the 85 prescriptions issued (with a range of 1 to 10 prescriptions per doctor). If the experience in Washington is similar, however, there will eventually be more prescriptions and deaths because Washington has more people (6.5 million, as compared with 3.7 million in Oregon).
Whereas physicians and health care organizations in Oregon had 3 years to prepare for their state's Death with Dignity Act (there were legal challenges, and ballot measures passed in 1994 and 1997), those in Washington will have only several months. Thus, physicians, hospitals, hospices, and other entities involved in the care of terminally ill patients will need to rapidly become familiar with the initiative and develop appropriate policies and procedures, including those for referrals. Some physicians and institutions will not participate because of religious or moral objections to the law. Of course, Oregon's well-documented experiences are an invaluable resource; a comprehensive guidebook for health care professionals is available online and was recently updated.4
As in Oregon, the Washington initiative requires that an attending physician and a consulting physician independently determine that a patient is qualified to initiate a written request for a prescription for a lethal medication — a determination that includes verification that the person is competent, is acting voluntarily, and has made an informed decision. Medications must not be prescribed to a patient "suffering from a psychiatric or psychological disorder or depression causing impaired judgment." If such disorders are suspected, the patient must be referred to a psychiatrist or psychologist for counseling, a determination of whether or not the patient's judgment is impaired, and possible treatment.
Although the Oregon law has been successfully implemented, it is concerning that in 2007 none of the 85 patients who received prescriptions for lethal medications were referred for psychiatric evaluations, whereas 12.6% of those who received prescriptions between 1998 and 2006 did receive such referrals. A study conducted between 2004 and 2006 suggested that not all patients in Oregon who request a physician's aid in dying are adequately screened for depression and that "some potentially ineligible patients" may have received a prescription for a lethal drug.5
Physicians will continue to disagree about the wisdom of prescribing lethal doses of medication to terminally ill people who want to hasten their own deaths. Nonetheless, the approval of the Washington initiative and the potential for similar legal changes in other states provide the medical profession with an opportunity to evaluate what can be done to continue to improve care at the end of life.
Source Information
Dr. Steinbrook (rsteinbrook{at}attglobal.net) is a national correspondent for the Journal.
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