On January 17 the U.S. Supreme Court upheld oregon's assisted-suicide law,
which lets physicians help terminally ill patients end their lives
(Psychiatric News, March 3). The decision paves the way for any other
state that wants to adopt a similar law, and a few are considering it.
"Booth Gardner, who was a two-term governor in Washington state, has
said that he will lead an initiative effort in Washington on assisted
dying," Len Eddinger, senior director of legislative and regulatory
affairs for the Washington State Medical Association, told Psychiatric
"There has been a bill in the Vermont legislature for the last
several years that would allow physician-assisted suicide," Steve
Larose, executive secretary of the Vermont Psychiatric Association,
"Yes, we do have a bill such as Oregon's, it's AB 651 (Berg, Levine),
California's Compassionate Choices Act," Randall Hagar, director of
government affairs for the California Psychiatric Association, told
Psychiatric News. "The bill passed our Assembly on strict
party-line votes last June," he said, but it failed to make it out of
the Senate Judiciary Committee after discussions in June of this year."
It never reached the Senate floor because there were key issues that
remained unresolved between the authors and a powerful committee chair,"
Hagar noted. "Those concerns had to do with whether or not the bill had
adequate protections in it to protect patients from coercion."
Hagar said that according to a representative of Assembly Rep. Patty Berg,
who co-authored the bill, she and co-author Rep. Lloyd Levine intend to
reevaluate their options regarding the bill in the coming months, but both"
remain committed to the issue."
Although the future of assisted suicide in these and other states is far
from clear, what is more evident is the impact that Oregon's assisted-suicide
law has had on that state's clinicians and terminally ill patients since it
took effect on November 5, 1997.
The bulk of that information comes from the Oregon Department of Human
Services-Health Services, which is legally required to monitor compliance with
the law, collect information about patients and physicians who participate in
physician-assisted suicide, and publish an annual statistical report. Linda
Ganzini, M.D., a professor of psychiatry at Oregon Health and Science
University, and her colleagues have also published studies on the subject.
Those physicians who are in the front line of dealing with patients who
want assisted suicide are mostly family practitioners, oncologists, and
internists, according to the Eighth Annual Report on Oregon's Death With
Dignity Act, published in March by Oregon's Department of Human
However, under the Oregon assisted-suicide law, not just the attending
physician but a consulting physician must agree on a patient's diagnosis and
prognosis before he or she can be eligible for assisted suicide—that is,
the patient must be diagnosed with a terminal illness that will lead to death
within six months. Moreover, if either the attending or consulting physician
believes that the patient's judgment is impaired by depression or another
psychiatric disorder, then that patient must undergo a mental health
evaluation, Darcy Niemeyer explained in an interview. Niemeyer oversaw the
Eighth Annual Report on Oregon's Death With Dignity Act. She was
assisted by epidemiologists Richard Leman, M.D., and Melvin Kohn, M.D., and by
statistician David Hopkins.
The mental health evaluations can be conducted by either psychiatrists or
psychologists, Niemeyer noted, although "so far, all
physician-assisted-suicide evaluations have actually been performed by
psychiatrists, and all have been for evaluation of depression."
And just as patients' mental health can influence their desire for assisted
suicide, patients' requests for assisted suicide can influence the mental
health of physicians who are asked to participate, Ganzini and her coworkers
reported in the May/June 2004 Journal of Palliative Medicine.
Semistructured interviews were conducted with 35 Oregon physicians who had
received assisted-suicide requests from patients. The interview results
revealed that the physicians often felt unprepared and experienced
apprehension and discomfort before and after getting requests. The physicians
were especially concerned about adequately managing patients' suffering, not
wanting to abandon patients, and not completely understanding patients'
preferences, especially when they did not know the patients well.
On the other hand, regardless of whether they prescribed lethal medications
for assisted-suicide patients, the physicians did not express major regrets
about their decisions and indicated that requests for assisted suicide helped
them discuss crucial end-of-life issues with patients.
Indeed, a number of end-of-life issues have propelled patients to request
assisted suicide since the law went into effect, the Oregon report reveals.
The concerns of greatest importance to patients have been loss of autonomy,
decreasing ability to participate in activities that make life enjoyable, and
loss of dignity.
Concerns of lesser importance included a loss of control over body
functions, fear of being a burden to family and friends, inadequate pain
control, and the financial implications of treatment.
And as to why patients with amyotrophic lateral sclerosis (ALS) in
particular have sought assisted suicide, a study conducted by Ganzini and
colleagues and published in the September 2002 Journal of Pain and Symptom
Management offers some insights.
Information was gathered on how 50 patients with ALS felt during the months
before they died—for example, whether they were depressed, felt
hopeless, or were in pain and how much social support they had—and
whether they wanted assisted suicide.
One-third of the ALS patients discussed the option of assisted suicide
during the last month of life. Hopelessness at the start of the study
predicted a desire for assisted suicide later on. A major depressive disorder
at the start of the study, however, did not. (This finding is at odds with one
reported by William Breitbart, M.D., chief of the psychiatry service at
Memorial Sloan-Kettering Cancer Center, in the December 13, 2000
JAMA. That study found that hopelessness and depression
contributed to terminally ill patients' desire for a hastened death.)
By the end of 2005, 390 individuals in Oregon had obtained lethal
prescriptions, and 246 had used them to die, according to the report on
Oregon's Death With Dignity Act. Although there are year-to-year variations in
the characteristics of patients who used assisted suicide, certain demographic
patterns have become evident. Males and females were equally likely to use it.
Divorced and never-married persons were more likely to use it than were
married or widowed individuals. A higher level of education has been strongly
linked with its use. Patients with certain types of terminal illnesses, such
as ALS, AIDS, and cancer, are especially likely to take advantage of it.
Oregon's health department does not track the persons who wanted assisted
suicide yet were screened out after getting a mental health evaluation,
Niemeyer explained. However, the department does track those who are not
eliminated after a mental health exam. Thus, data show that out of the 246
individuals who died by assisted suicide by the end of 2005, 212 (86 percent)
had not received a mental health evaluation before-hand, yet 34 (14 percent)
had. And the reason why the 86 percent had not gotten such an evaluation was
because their attending and consulting physicians did not think that their
judgment was marred by mental illness; the reason that the 14 percent had
received such an evaluation was because their attending and consulting
physicians suspected that their judgment might be impaired.
Of 67 patients who wanted to use assisted suicide, but were given pain
control, anti-depressant medication, referral to a hospice program, or other
substantive help, 46 percent changed their minds, Ganzini and her team
reported in the February 24, 2000 New England Journal of
In contrast, only 15 percent of 73 patients for whom no substantive
intervention was made changed their minds. (A new study finding by Breitbart
and his group, and shared with Psychiatric News, complements these
results. They have found that treating depression helps reduce patients'
desire for a hastened death.)
Even with these insights, though, a lot about the impact of Oregon's
assisted-suicide law on Oregon clinicians and terminally ill patients is not
publicly available. "That is why, once again, we call for open and
impartial review of anonymous assisted-suicide cases in Oregon," N.
Gregory Hamilton, M.D., an Oregon psychiatrist, argued in a letter published
in the June American Journal of Psychiatry.
The "Eighth Annual Report on Oregon's Death With Dignity
Act" is posted at<www.Oregon.gov/DHS/ph/pas/docs/year8.pdf>.▪