Policy Analysis: Oregons Death with Dignity Act

On October 27, 1997 the Death with Dignity Act became law in Oregon. Oregon’s Death with Dignity Act deals with the controversial moral issue of physician assisted suicide. According to Altmann and Collins (2007) moral policies are often easy for the public to understand, but are often debated. These policies “are driven by public opinion, mass media coverage, the strength of relevant interest groups, the political vulnerability of elected officials and sometimes by ideology” (Altmann, & Collins, 2007).

Oregon’s Death with Dignity Act and the issue of physician assisted suicide grew out of the debate over a patient’s right to die. Living wills were one of the first steps to the patient’s rights and patient’s right to die, but they apply better to the end stages of life than they are to those in the early stages of terminal illness. The United States people are living longer with chronic illnesses which often means they end up suffering longer. The basic ideology behind physician assisted suicide for most doctors and nurses is the idea of helping improve a patient’s situation and end their suffering. One solution to the problem of patients suffering from terminal illness is improved end of life treatments like as pain control. Another solution is improved services for end of life care including resources like hospice. Most patients are not eligible of these services until their last weeks of life if they are eligible at all. Further more, another solution is simple, not prolonging the misery of the patient and their family; this is the solution that Oregon’s Death with Dignity Act is aimed at (Altmann & Collins, 2007).

In 1980, the Hemlock Society was founded and started to advocate for legal changes of patient’s right to die. They were known for distributed information on assisted dying. In 1987 the Hemlock Society along with support of other organizations initiated a movement to put physician assisted suicide on the ballot in California in 1988. In 1990 the controversy continued when Dr. Jack Kevorkian assisted a terminally ill patient to commit suicide which received extensive media coverage (Rich, 2002; Altmann, & Collins, 2007). This was only the first of nearly 130 assisted suicides committed by Dr. Kevorkian. Also in 1990, the Hemlock society facilitated the introduction of the Death with Dignity Act in Oregon. In 1991 Washington State attempted to legalize physician assisted suicide and in 1992 California did the same (Altmann & Collins, 2007).

A political action committee, Oregon Right to Die, was founded in 1993 in response to increasing support for physician assisted suicide. By early 1994 all fifty states and the District of Columbia recognized at least some sort of advanced directive and a federal district judge in Washington declared Washington’s law that banned assisted suicide unconstitutional (Altmann, & Collins, 2007).

Nearly a year after Oregon Right to Die was enacted, the Oregon death with Dignity Act was passed.

Around this same time, between 1994 and 1996 many western states passed laws prohibiting assisted suicide. In 1996 federal court struck down a law that was attempting to be passed in New York that would prohibit assisted suicide. In 1997, the US Supreme Court decided that patients did not have a constitutional right to assist suicide, but they did have the right to decide if they wanted treatment or wanted treatment to be withheld or withdrawn (Miller, 2003). With Oregon’s Death with Dignity Act being delayed by legal challenges, in April of 1997, the House of Representatives passed a bill known as Assisted Suicide Funding Restriction Act on 1997 which would ban any federal funding to pay for physician assisted suicide. It was then passed by the Senate and signed by President Bill Clinton. The law also authorized more funding for pain treatment research and suicide prevention (Altmann, & Collins, 2007).

In May 1997 the Oregon House of Representatives voted to return the Act to the voters. After some back and forth in the House and Senate, on November 4th 1997 60% of voters voted in favor of the Death with Dignity Act and in early 1998 the first two legal physicians assisted suicides were announced (Miller, 2003; Altmann, & Collins, 2007; Lindsay, 2009).

In order to guide the implementation of the new Death with Dignity Act, the Oregon Health Division was given the role of assisting implementation and the Task Force to Improve the Care of Terminally Ill Oregonians was formed. The Oregon Health Division was asked to monitor compliance with the law and to collect data on the patients, physicians, and all who participate in legal physician assisted suicide. There are two components, the first being a form that physicians are made to complete upon writing the prescription for lethal medication and the second involves a review of the death certificates of each of the assisted suicides in order to ensure they match the prescribing physician’s report. In 1998 the Oregon Health Division published a guidebook for physicians which set aside voluntary guidelines for physicians, pharmacists, and nurses (Altmann, & Collins, 2007).

Typically in the United States health policies grow out of modifications to current health policies, however, with Oregon’s Death with Dignity Act being a brand new policy, some omissions and unintended consequences have been found and are being address even ten years later (Altmann, & Collins, 2007). Those that oppose the act raise many concerns. One being that it appears that there is no physician responsibility beyond the preparation and writing of the prescription and the form they have to fill out for the government, the second being a concern about consent and who really determines consent. Because of great concern, the advocacy group Compassion and Choices of Oregon was formed and has compiled a list of supports for those individuals looking to seek end of life options. This group also provides emotional, social, and spiritual supports and information about hospice, refusing treatment, and professional supports such as physicians, mental health professionals, attorneys, and clergy (Altmann, & Collins, 2007).

Currently there are two steps in receiving the lethal medication which constitutes physician assisted suicide. The first step being requesting the lethal medication, and the second being receiving the prescription. In order to request the lethal medication, the patient must be over 18, a resident of Oregon, mentally capable of making health care decisions, and be diagnosed with a terminal illness that will cause death within the next 6 months (Altmann, & Collins, 2007; “Death with dignity,” 2011; Lunge, Royle, & Slater, 2004; Rich, 2002; Sclar, 2006). In order to receive the prescription the patient must make two verbal requests to their physician that are 15 days apart, they must provide written request with two witnesses, the physician and another consulting physician must confirm their diagnosis and prognosis, the physicians must determine decision making capacity of the patient, the patient must be referred to counseling with a mental health professional if the physician believes the patient may be impaired in decision making abilities, the patient must be informed of all other alternatives to physician assisted suicide, and lastly the physician must request that the patient notify their friends and family of their decision (Altmann, & Collins, 2007; “Death with dignity,” 2011; Lunge, Royle, & Slater, 2004; Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005).

Some changes have occurred since the Act was put into place in 1997. One of these provides a safeguard for patients, stating that physicians must work with the pharmacist to tailor a prescription for the individual patient. Secondly, the physician must report to the Oregon Health Division all lethal prescriptions that have prescribed, but they do not have to report all of the requests they receive (“Death with dignity,” 2011; Altmann, & Collins, 2007). If the physician does not comply with this part of they law they can be prosecuted. Also, tweaks have been made to the act stating that the physicians, pharmacists, and health care systems do not have to participate in physician assisted suicide and may choose on an individual basis if they will participate. There are some other safeguards for the patient, one being that the choice of legal physician assisted suicide is not allowed to affect that status of a patient’s health or life insurance policy. Also, choosing to end your life using physician assisted suicide does not constitute suicide according to the law, health insurance, and life insurance (Altmann, & Collins, 2007).

Physician assisted suicide is still quite controversial and always has been. In November of 2001 the United States Attorney General John Ashcroft issued a new interpretation of the Controlled Substance act that stated that “the prescribing, dispensing, or administering federally controlled substances to assist suicide violated the act.” All of the prescriptions used for physician assisted suicide are barbiturates, which are controlled substances (Altmann, & Collins, 2007; Lunge, Royle, & Slater, 2004; Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005). Therefore this new interpretation would allow the Drug Enforcement Agency to stop physicians who prescribe these medications under the Oregon Death with Dignity Act. In 2004, Ashcroft appealed the case to the United States Supreme Court and in 2005 the hearing began. In January of 2006 the United States Supreme Court ruled Oregon’s law remain in effect (Altmann, & Collins, 2007; Lunge, Royle, & Slater, 2004;Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005).

No law is perfect and Oregon’s Death with Dignity Act is no different. The primary method of tracking and feedback of implementation of the law comes in the form of annual reports that are published by the Department of Human Services (Altmann, & Collins, 2007). According to Oregon Public Health Division in 2011, the number of prescriptions written under the Oregon Death with Dignity Act have increased from 1998-2010 steadily, but have not been found to be being abused. Of those receiving prescriptions under the law, only approximately 65% of them take the prescription and end their lives (“Death with dignity,” 2011). When polled in 2005, 84% of nationwide respondents approved of the right to die laws, but were still divided about physician assisted suicide (Altmann, & Collins, 2007).

Opponents of the law have valid views on the law and what possible abuses of the law may occur, but for the most part research and annual reports have shown these worries to not be occurring. Opponents often believe patients feel pressured by the law and lack the resources to articulate their desire to live. When polled, physicians reported that the patient’s top three reasons for requesting physician assisted suicide were loss of dignity (89%), decrease in ability to enjoy life (89%), and loss of autonomy (79%) (Altmann, & Collins, 2007; Lunge, Royle, & Slater, 2004). (Interesting info)Worries over cost of health care only comprised 1% of the respondent’s reasons for asking for physician assisted suicide. Due to these concerns, some changes have been put into place, including making pharmacists to be informed of the medication’s intended use (Altmann, & Collins, 2007).

One of the biggest benefits of the Oregon Death with Dignity act according to Altmann and Collins (2007) is the opportunity for physicians to discuss fears and desires for end of life care with patients. Approximately 17% of terminally ill patients seriously discuss with their doctors the option of physician assisted suicide, and only 2% make the formal request (Altmann, & Collins, 2007). In 2010, their was only one referral to the Oregon Medical Board concerning the law when a physician did not wait the required 48 hours to write the prescription after the patient had provided written request (“Death with dignity,” 2011).

The author of this analysis has a handful of recommendations to modify the law in order to make it safer and more effective for its purpose. According to Oregon’s Public Health Division physicians are not required to be present at the time the patient ingests the medication and therefore not all of the information regarding patient’s death and the circumstances surrounding their death are known or reported (“Death with dignity,” 2011). In 2010 the law was modified and the follow up questionnaire for the physician does ask about the circumstances surrounding the death if the physician was present, but this still does not require the physician to be present (“Death with dignity,” 2011). The author believes it would be an important modification of the law for physicians to be present for the ingestion of the medication and all information regarding the death and ingestion should be required to be reported to the Public Health Division in order to better track and understand the circumstances of the death. This would also be important to implement because it has been found that on rare occasions patients will ingest the medication and later regurgitate it, experienced seizures, or awakening and living after taking the prescriptions (“Death with dignity,” 2011). These occurrences are rare, but possible and it would be helpful for the patient to be in a health care setting with the physician present in the rare case that these things occur.

Another recommendation for change in Oregon’s Death with Dignity Act would be requiring physicians to inquire about the reasons for physician assisted suicide. Often times patients feel the pressure to relieve their family and friends from the burden their illness has caused and by require a discussion and reporting of the patient’s main reasons for requesting physician assisted suicide would allow the physician and mental health worker to better understand their mental abilities to make a sound decision regarding the end of their life (Werth, & Wineberg, 2005).

Another modification, according to the author, would be important is requiring all patients requesting lethal medication be evaluated for mental health by a psychiatrist or psychologist. Research has shown medical physicians are less attune to patient’s mental state than psychiatrists or psychologists and according to the law as it stands today, the patient is only required to be mentally capable of making decisions and if the physician thinks it is necessary for a mental health evaluation are the patient’s required to receive an evaluation (Altmann, & Collins, 2007).

It is important not only for social workers to be aware of laws in their own states but also laws and policies being debated and implemented in other states. Social workers need to keep up with political actions in the United States that have the potential to affect their clients and their future clients (good point). The Oregon Death with Dignity Act is not the first and will not be the last policy regarding a patient’s right to die and this subject is highly debated and very controversial.

This policy is aimed and assisting terminally ill patients over the age of 18 to have their choice in how they die. These terminally ill patients have often times been terminally ill for years and have suffered tremendously. They deserve the option to be informed of all end of life care, including physician assisted suicide. It would be a shame if patients were kept alive against their will and occasionally in these situations patients will go to extremes to cause their death and Oregon’s Death with Dignity Act allows patients the option of physician assisted suicide and allows them to have complete control over the process. They are allowed to rescind their request at any point and they also have the option after being prescribed the lethal medication of not actually ingesting it (Lindsay, 2009). This part of the law allows patients to have control over their care and have power in a very vulnerable and questionable situation.

Overall, Oregon’s Death with Dignity Act is functioning as it was expected to and fulfilling its goals. There are a few tweaks that need to be made in order for the law to fully function as it was designed. Terminally ill patients have the right to die with dignity and Oregon’s Death with Dignity Act is attempting to give them this opportunity.

References

Altmann, T. K., & Collins, S. E. (2007). Oregon’s death with dignity act (ors 127.800- 897): a health policy analysis. Journal of Nursing Law, 11(1), 43-52.

Death with dignity. (2011). Retrieved from http://www.oregon.gov/DHS/ph/pas/

Lindsay, R. A. (2009). Oregon’s experience: evaluating the record. The American Journal of Bioethics, 9(3), 19-27.

Lunge, R., Royle, M., & Slater, M. (2004). Oregon’s death with dignity law and euthanasia in the netherlands: factual disputes. Retrieved from http://www.leg.state.vt.us/reports/05death/death_with_dignity_report.htm

Miller, C. (2003). A death by any other name: the federal government’s inconsistent treatment of drugs used in lethal injections and physician assisted suicide. Journal of Law and Heath, 17, 217-240.

Rich, B. A. . (2002). Oregon versus Ashcroft: pain relief, physician -assisted suicide and the controlled substances act. Pain Medicine, 3(4), 353-360.

Sclar, D. (2006). U. S. Supreme Court Ruling in Gonzales v. Oregon: upholds the Oregon death with dignity act. Journal of Law, Medicine, and Ethics, 34(3), 639-645.

Werth, J. L. , & Wineberg, H. (2005). A critical analysis of criticisms of the Oregon death with dignity act. Death Studies, 29, 1-27.

Policy Analysis: Oregon’s Death with Dignity Act

Remember final paper must be submitted anonymously University of Kentucky

Introduction

On October 27, 1997 the Death with Dignity Act became a law in Oregon. This act legalized physician assisted suicide. This act was rooted in a moral dilemma of the right to die and the terminally ill patient’s rights and the right they have to die if they so choose. Awkward sentence Proposals of policies such as this began in the early 1900s. These policies first looked at active euthanasia as the deliberate and intentional act that causes the death of a patient at his or her request. After these policies first debuted, legislation addressed advanced directives. These are documents are created by the patient that indicate their desires for or against life sustaining measures, such as a feeding tube, CPR and breathing machines. Currently the focus has moved to physician assisted suicide (Altmann, & Collins, 2007). Oregon’s Death with Dignity Act deals with the moral issue, physician assisted suicide. According to Altmann and Collins (2007) morality policies are simple to understand by the general public and are prone to great disagreement. These policies “are driven by public opinion, mass media coverage, the strength of relevant interest groups, the political vulnerability of elected officials and sometimes by ideology” (Altmann, & Collins, 2007).

Oregon’s Death with Dignity Act and the issue of physician assisted suicide grew out of the debate over a patient’s right to die. Living wills were one of the first steps to the patient’s rights and patient’s right to die but they are more applicable to the final stages of life and the stage of death than they are to those in the early stages of incapacitation and fatal illness. In our aging population people are living longer with chronic illnesses which often times means they are suffering more and being more tormented by impending death. Because of this patients are more often stating their belief that they have a right to control their suffering and to decide when and how they will eventually die. The fundamental ideology behind physician assisted suicide for most doctors and nurses is the idea of helping improve a patient’s situation and end their suffering. One solution to the problem of patients suffering of terminal illness is improved end of life treatments such as pain control. Another solution is improved services for end of life care including hospice and palliative care. Most often patients are not eligible of these services until their last weeks of life if they are eligible at all. Further more, another solution is simple not prolonging the misery of the patient and their family; this is the solution that Oregon’s Death with Dignity Act is aimed at (Altmann & Collins, 2007).

Physician assisted suicide grew out of a debate over patient’s right to die. The first bill considering assisted suicide was put forward in Ohio in 1906, but was not developed or implemented. In 1967 the first living will was written and the first right to die bill was introduced in Florida. There were a variety of political debates over the topic and it became even more widely discussed in 1976 when the parents of Karen Ann Quilan desired to disconnect her feeding tube as her living will has discussed. Also in 1976, eleven other states passed laws giving legal status to living wills (Altmann & Collins, 2007).

In 1980, the Hemlock Society was founded and started to advocate for legal changes on the subject of patient’s right to die. They distributed information on assisted dying. In 1987 the Hemlock Society along with support of other organizations and groups of people initiated a movement to put physician assisted suicide on the ballot in California in 1988. In 1990 the controversy continued when Dr. Jack Kevorkian assisted a terminally ill patient to commit suicide and the issue received extensive media coverage (Rich, 2002; Altmann, & Collins, 2007). maybe take out “and the issue” exchange with “which” This was only the first of nearly 130 assisted suicides committed by Dr. Kevorkian. Also in 1990 the Supreme Court allowed for Nancy Beth Cruzan the right to refuse treatment and in this same year the Hemlock society facilitated the introduction of the Death with Dignity Act in Oregon. In 1991 Washington State attempted to legalize physician assisted suicide and in 1992 California did the same (Altmann & Collins, 2007).

With support for physician assisted suicide came various arguments against it. Many stated that physician assisted suicide “leads to morally unacceptable outcomes and if it required another person to assist, would require alteration of professional societies’ rules of ethical conduct” (Altmann & Collins, 2007). Considering this argument, The American Association of Critical Care Nurses and the International Council of Nursing both began to include a portion of their ethics to state that aid it dying constituted abandonment of the patient which was unacceptable. The Catholic Hospital Association also objects to physician assisted suicide on religious grounds (Altmann, & Collins, 2007).

Public support for physician assisted suicide began to increase according to public opinion polls in the early 1990s. Medical literature also began covering physician assisted suicide more between 1993 and 1996. A political action committee, Oregon Right to Die, was founded in 1993 in response to increasing support for physician assisted suicide. At this same time Dr. Kevorkian was becoming a well known figure for his assisted suicides. By early 1994 all states and the District of Columbia recognized at least some sort of advanced directive and a federal district judge in Washington declared Washington’s law that banned assisted suicide unconstitutional (Altmann, & Collins, 2007).

Nearly a year after Oregon Right to Die was enacted a referendum that would legalize physician assisted suicide; the Oregon death with Dignity Act was passed. This was a citizens’ initiative that was instigated by the Oregon Right to Die Coalition. Political parties and medical association either endorsed the measure or had a neutral position (Altmann, & Collins, 2007).

Immediately after the Oregon Death with Dignity Act passed with 51% of the vote, many lawsuits were filed that proposed the act which caused a delay in its passing (Altmann, & Collins, 2007; Miller, 2003; Werth, & Wineberg, 2005). One of the first lawsuits filed was brought by a group of doctors who sued on the grounds that this act violated the Equal Protection and Due Process Clauses of the 14th amendment and sated that the “bill did not sufficiently guarantee that a patient’s choice to end his or her life would be truly informed and/or voluntary.” Then shortly thereafter the law was found to be unconstitutional and suspended in August of 1995 (Altmann, & Collins, 2007).

Around this same time between 1994 and 1996 many western states passed laws prohibiting assisted suicide. I think if you take out the word “had” the sentence will read the same. Then in 1996 federal court struck down a law that was attempting to be passed in New York that would prohibit assisted suicide. In 1997 the US Supreme Court decided that patients did not have a constitutional right to assist suicide but they did have the right to decide if they wanted treatment or wanted treatment to be withheld or withdrawn (Miller, 2003; Altmann, & Collins, 2007 ). With Oregon’s Death with Dignity Act being delayed by legal injections in April of 1997, the House of Representatives passed a bill known as Assisted Suicide Funding Restriction Act on 1997 which would ban any federal funding to pay for physician assisted suicide. It was then passed by the Senate and signed by President Bill Clinton. The law also authorized more funding for pain treatment research and suicide prevention (Altmann, & Collins, 2007).

In May 1997 the Oregon House of Representatives voted to return the Act to the voters. After some back and forth in the House and Senate, on November 4th 1997 60% of voters voted in favor of the Death with Dignity Act and in early 1998 the first two legal physicians assisted suicides were announced (Miller, 2003; Altmann, & Collins, 2007; Lindsay, 2009).

Act

In order to guide the implementation of the new Death with Dignity Act, the Oregon Health Division was given the role of assisting implementation and the Task Force to Improve the Care of Terminally Ill Oregonians was formed. The Oregon Health Division was asked to monitor compliance with the law and to collect data on the patients, physicians, and all who participate in legal physician assisted suicide. There are two components, the first being a form that physicians are made to complete upon writing the prescription for lethal medication and the second involves a review of the death certificates of each of the assisted suicides in order to ensure they match the prescribing physician’s report. In 1998 the Oregon Health Division published a guidebook for physicians which set aside voluntary guidelines for physicians, pharmacists, and nurses (Altmann, & Collins, 2007).

Those that oppose the act raise many concerns. One being that it appears that there is no physician responsibility beyond the preparation and writing of the prescription and the form they have to fill out for the government, the second being a concern about consent and who really determines consent. Because of great concern, the advocacy group Compassion and Choices of Oregon was formed and has compiled a list of supports for those individuals looking to seek end of life options. This group also provides emotional, social, and spiritual supports and information about hospice, refusing treatment, and professional supports such as physicians, mental health professionals, attorneys, and clergy (Altmann, & Collins, 2007).

Typically in the United States health policies grow out of modifications to current health policies, however, with Oregon’s Death with Dignity Act being a brand new policy, some omissions and unintended consequences have been found and are being address even ten years later (Altmann, & Collins, 2007).

Currently there are two steps in receiving the lethal medication which constitutes physician assisted suicide. The first step being requesting the lethal medication, and the second being receiving the prescription. In order to request the lethal medication, the patient must be over 18, a resident of Oregon, mentally capable of making health care decisions, and be diagnosed with a terminal illness that will cause death within the next 6 months (Altmann, & Collins, 2007; “Death with dignity,” 2011; Lunge, Royle, & Slater, 2004; Rich, 2002; Sclar, 2006).Interesting informationIn order to receive the prescription the patient must make two verbal requests to their physician that are 15 days apart, they must provide written request with two witnesses, the physician and another consulting physician must confirm their diagnosis and prognosis, the physicians must determine decision making capacity of the patient, the patient must be referred to counseling with a mental health professional if the physician believes the patient may be impaired in decision making abilities, the patient must be informed of all other alternatives to physician assisted suicide, and lastly the physician must request that the patient notify their friends and family of their decision (Altmann, & Collins, 2007; “Death with dignity,” 2011; Lunge, Royle, & Slater, 2004; Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005). Interesting section

Some changes that have occurred since the Act was put into place in 1997. One of these safeguards for patients is that the physician must work with the pharmacist to tailor a prescription for the individual patient. Secondly, the physician must report all lethal prescriptions that have prescribed, but they do not have to report all of the requests they receive (Death with dignity,” 2011; Altmann, & Collins, 2007). If the physician does not comply with this part of they law they can be prosecuted. Also tweaks have been made to the act stating that the physicians, pharmacists, and health care systems do not have to participate in physician assisted suicide and may choose on an individual basis if they will participate. There are some other safeguards for the patient, one being that the choice of legal physician assisted suicide is not allowed to affect that status of a patient’s health or life insurance policy. Also, choosing to end your life using physician assisted suicide does not constitute suicide according to the law, health insurance, and life insurance (Altmann, & Collins, 2007).

Purpose

Challenges to the Law

Physician assisted suicide is still quite controversial and always has been. In November of 2001 the United States Attorney General John Ashcroft issued a new interpretation of the Controlled Substance act that stated that “the prescribing, dispensing, or administering federally controlled substances to assist suicide violated the act.” All of the prescriptions used for physician assisted suicide are barbiturates, which are controlled substances (Altmann, & Collins, 2007; Lunge, Royle, & Slater, 2004; Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005). Therefore this new interpretation would allow the drug Enforcement Agency to stop the ability of physicians to prescribe these medications under the Oregon Death with Dignity Act. In 2004, Ashcroft appealed the case to the United States Supreme Court and in 2005 the hearing began. In January of 2006 the United States Supreme Court ruled Oregon’s law remain in effect (Altmann, & Collins, 2007; Lunge, Royle, & Slater, 2004;Rich, 2002 Sclar, 2006; Werth, & Wineberg, 2005).

Analysis

No law is perfect and Oregon’s Death with Dignity Act is no different. The primary method of tracking and feedback of implementation of the law comes in the form of annual reports that are published by the Department of Human Services (Altmann, & Collins, 2007). According to Oregon Public Health Division in 2011, the number of prescriptions written under the Oregon Death with Dignity Act have increased from 1998-2010 steadily, but have not been found to be being abused. Of those