FEAR OF DISABILITY AND "BEING A BURDEN" MOTIVATES SUICIDES, NEW OREGON STUDY SHOWS; MAINE POLL, IN SHIFT, SHOWS MAJORITY OPPOSITION

By Department of Medical Ethics

February 23 saw the release of the Oregon Health Division's official report on the 27 patients killed by legalized physician-assisted suicide during 1999 (a 69% increase over 16 in 1998), together with new studies raising questions about the practice both in that state and in the Netherlands ­ all published in the New England Journal of Medicine (NEJM).

In a related development, a newspaper poll released March 6 in Maine, showed a dramatic decrease in support for an Oregon-style measure to legalize assisting suicide that will be on the November ballot. The poll reveals that support has dropped from 71% two years ago to just 38% today.

Meanwhile, outrage mounted after two Hawaiians suffering from depression but no terminal illness killed themselves within 24 hours of the television airing of a Derek Humphry "how-to" video in Hawaii. The two used methods the video described in explicit detail.

Oregon's second annual official report on deaths under that state's unique-in-the-nation suicide law found that in 47% of cases, one of the motivations for assisted suicide was "concern about being a burden on others," according to family members. The finding tends to corroborate warnings that the "right to die" would soon be perceived as a "duty to die."

Indeed, a 1998 book written by Humphry, founder of the pro-euthanasia Hemlock Society, said that "economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice." Suggesting that money spent on those who are ill or have disabilities might "be better spent" on other things, Humphry asked, "Is there, in fact, a duty to die­a responsibility within the family unit ­ that should remain voluntary but expected nevertheless?"

The official report shows that such an attitude is taking hold among many of the Oregonians who request lethal prescriptions.

The NEJM report also found that a predominant motivation for suicide was not pain but fear of future disability. The two reasons most frequently cited were "concern about loss of control of bodily functions" (68%) and "loss of autonomy" (63%).

This is consistent with the previous year's report, which nevertheless noted that those whose suicides were assisted at the time of death were less disabled than a control group of patients who did not commit suicide.

"Disability rights activists point out that non-disabled people all too often have a distorted and negative view of the quality of life with a disability, and that newly disabled people go through an adjustment period before realizing this," commented Burke Balch, J.D., director of NRLC's Department of Medical Ethics. "Tragically, those whose fear of disability led to their deaths in Oregon will never have that opportunity."

The report also confirmed that all 43 deaths officially reported since legalization were caused by federally controlled substances (barbiturates). The Pain Relief Promotion Act, now pending in the U.S. Senate after being passed 271-156 by the House last fall, would end their use for that purpose. (See Action Alert, p. 7)

Another study published in the same issue of the NEJM, based on a survey of Oregon physicians conducted by Dr. Linda Ganzini and others, demonstrates that those requesting to be killed who are provided positive alternatives are far less likely to follow through on their expressed wish to die than those who do not receive such care. Forty-six percent of such patients who received substantive interventions, (such as pain control, hospice care, or treatment of depression) changed their minds, compared to 15% of those who received no such assistance.

Relying on studies showing that a high proportion of the suicidal terminally ill are depressed - - and that primary care physicians frequently fail to recognize the symptoms of depression - - many experts have criticized the Oregon's law's provision requiring a psychiatric consultation only when the primary physician feels it is needed, rather than in all cases. The Ganzini et al study noted that although the published literature reports depression in 59% to 100% of terminally ill patients interested in hastening death, the Oregon doctors diagnosed only 20% of their patients as depressed.

A separate report appeared in the NEJM on euthanasia and assisted suicide in the Netherlands. Both practices have effectively been legal for years as the result of Dutch court rulings.

The study found that lethal drugs did not work as expected in 16% of the cases. Death took much longer than expected; patients experienced vomiting, nausea, and extreme gasping; and in two cases patients awoke from a drug-induced coma intended to be fatal. In 18% of cases in which patients ingested lethal drugs, doctors felt compelled to administer euthanasia themselves because the self-induced suicides were not working as planned.

This data led legalized assisted suicide advocate Dr. Sherwin Nuland to concede in a NEJM editorial that "patients who wish to receive help in dying face a small but nevertheless worrisome possibility that some untoward event will prevent the smooth accomplishment of their wish." To ensure that patients are efficiently put to death without such "untoward" complications, Nuland wrote, "thorough training in techniques must be made available ... with the attention to detail that all aspects of medical practice demand...." Nuland disparaged "the Hippocratic Oath and its prohibition on hastening death" as a "statement [that] has been embraced over approximately the past 200 years far more as a symbol of professional cohesion than for its content." Nuland called it "only a matter of time before organized medicine recognizes the pragmatic necessity to support physicians who feel they have a moral obligation to provide such assistance."

Support Drops

The Maine poll, conducted for the Bangor Daily News, provided 602 registered voters with the language of the question on legalizing assisting suicide as it will appear on the ballot in November. Fifty-three percent said they were opposed; 38% supported it, and 9% were undecided. The margin of error was 4%. The question was one of a number asked about the various measures that will be up for referendum vote in the state.

Two years ago, a poll of 450 people (with a 4.6% margin of error) found 71% in favor of legalizing assisting suicide.

In Hawaii, an explicit video on how to kill oneself, emphasizing methods involving suffocation and narrated by Derek Humphry, began airing at midnight March 1 on a public access station. On March 3 a man in his 60s, depressed over a failed relationship, committed suicide using the demonstrated method. The next day, a woman in her 40s with a history of clinical depression used the same method. Neither had a terminal illness.

Honolulu's First Deputy Medical Examiner Dr. Kanthi von Guenther was quoted by the Honolulu Star-Bulletin News saying she has never seen two suicides using the same method on the same weekend. "I don't think this was coincidence," she said. "Once they see the method, it encourages them to practice it, or if they are contemplating [suicide], it's an easy way out."

Psychiatrist Dr. Wayne Levy had spoken out against the broadcast even before it aired. Dr. Levy warned, "Even if you believe in assisted suicide for the terminally ill, educating the entire public about how to harm yourself is going to lead folks with depression and individuals under acute stress, can lead them, to attempt suicide and be successful," he said.

Contacted by the newspaper, Humphrey expressed no second thoughts about the video.

"[I]f these people are intent on suicide, and released themselves in a nonviolent way from their troubles, then I can live with that."

Editor's note. For a fuller description of Humphry's "how-to" video, see NRL News 2/00, page 10.