Oregon, at the vanguard of the seven US states that permit physician-assisted suicide, has released its report on the Death With Dignity Act for 2018. What does it show?
We should bear in mind that the document is based on self-reporting by doctors, not on independent research, so there is no assurance that it accurately reflects the extent either of the practice of assistance or of compliance with the act’s alleged “safeguards”. Even so, according to the report, the practice is becoming more common; it is expanding beyond patients with cancer; and more people say they are using the law because they feel they are a burden to others. In most cases, the ingestion and the death occur without medical supervision, in some cases death takes several hours, and occasionally it takes two, three or four days.
The report gives figures since 1997, when the law came into force, broken down into five-year periods. In the first period there were 129 deaths, and in next three periods there were 212, 340 and 610. In 2018 alone there were 168 deaths. On official figures since the law was introduced, there have been 2,217 lethal prescriptions leading to 1,459 deaths. The death rate has increased consistently, more than doubling every 10 years.
And for what reasons have these 1,459 people taken their lives? The main ones given are not fear of pain or inadequate symptom control. The most cited reason is loss of autonomy (95.5 per cent), closely followed by a decreasing ability to participate in enjoyable activities (94.6 per cent) and a perceived loss of dignity (87.4 per cent).
These figures have been consistent over time, but in recent years there has been a marked increase in the number of people who also cite fear of becoming a burden on family, friends or caregivers. In the first five-year period fear of becoming a burden was cited by more than a third. By 2018 this had risen to nearly two thirds. Clearly these reasons, and especially perception of being a burden, reflect social attitudes more than clinical reality.
Many, if not all, of us have times when we question the meaning or value of our life and it is at these times that we are most vulnerable to the implicit or explicit messages from those around us or from society. This is well illustrated in a letter written by the great, and much-missed, Catholic bioethicist Nicholas Tonti-Filippini:
“For several years, until I objected, I received from my health insurer a letter that tells me how much it costs the fund to maintain my health care. I dreaded receiving that letter and the psychological reasoning that would seem to have motivated it. Each year I was reminded how much of a burden I am to my community. The fear of being a burden is a major risk to the survival of those who are chronically ill. If euthanasia were lawful, that sense of burden would be greatly increased for there would be even greater moral pressure to relinquish one’s hold on a burdensome life.”
The report gives a breakdown of the medical basis of the patients’ “terminal illness”. Cancer remains the most common condition, but over the past 15 years it has declined from 84 per cent to 62.5 per cent. There has been a rise in neurological diseases, diseases of the heart and respiratory system, and a small number of “other illnesses” including “arthritis … kidney failure, and musculoskeletal systems disorders”. It is clear that this shift makes prognosis of death within six months more difficult. (A prognosis that can, in any case, be satisfied if a patient refuses a treatment that would otherwise prolong life for years).
Who are the physicians writing the prescriptions for lethal drugs? The report states that the 249 prescriptions in 2018 were written by 103 physicians, but also notes that one physician was responsible for 35 lethal prescriptions. Again, while the median time a patient had known a doctor was 10 weeks, the minimum was only one week. At least one doctor had given a prescription just 15 days after the first request. It is clear that at least some physicians are seeing multiple patients they have not previously known and are adhering only to the statutory minimum requirements.
Already in 2019 four bills have been introduced in Oregon, which if passed would further weaken the statutory requirements, removing the need for a six-month prognosis, allowing lethal injection as well as ingestion of lethal drugs, and reducing the 15-day waiting period. Even the current “safeguards” may not endure for much longer.
The Low Countries have led the slide down euthanasia’s slippery slope. It seems inevitable that, sooner or later, states like Oregon will follow. If the actual reasons that people are seeking assisted suicide in Oregon concern reduced autonomy, lack of enjoyment in life, loss of a sense of dignity or feeling a burden, how can this reasonably be restricted to people who are “terminally ill”? If people are not dying, but are suffering from disability, chronic pain or long-term mental illness, would it not be discrimination to deny them also a “death with dignity”?
David Jones, director of the Anscombe Bioethics Centre, Oxford