Most of us would rather not think about death. But in Oregon assisted suicides have been legal for more than 10 years. Katharine Whitehorn visits the US state that believes in death with dignity.
Woody Allen said he didn’t fear death — he just didn’t want to be there when it happened.
But some places have tried to bring death more under human control. Holland has an excellent assisted suicide plan and was the first country to adopt one. Less liberal ones exist in Belgium, Switzerland and Germany.
And there is Oregon in the United States. When the Pacific northwest state passed legislation in 1994 — finally implemented in 1997 — to make physician-assisted suicide (PAS) legal, there were dire predictions: the old and tiresome, the poor and the marginalised would be wiped out; people from other states would pour in; the state’s biggest city, Portland, would become the death city of the US.
There were nightmare memories of Jack Kevorkian, a maverick in Michigan who helped 130 people to kill themselves with no safeguards and who was known as Doctor Death: he only came out of prison last year.
Most importantly, there were fears that no one would bother with palliative care any more, because patients could simply be discontinued.
None of this has happened, although the British Medical Journal reported recently that doctors in Oregon prescribing lethal doses of barbiturates may on three occasions have administered them to people with clinical depression. In cases where there is doubt, patients should be referred to a psychiatrist, one of many safeguards in the legislation: a request must be made twice, two weeks apart, to prevent someone in a fit of gloom signing something they may later regret, and the signature must be witnessed by two people, only one of whom may be a relative — so no two avaricious offspring can shunt mom into her grave.
A doctor must also certify that the patient has not long to live and is of sound mind. The doctor can write a prescription for the lethal dose, but the patient, or someone chosen by the patient, must get it from a pharmacist — and any pharmacist who has moral objections can refuse to supply it.
A possible flood of suicidal incomers has been prevented by the fact that only residents can apply for PAS. If someone arrives, says that they want to live in Oregon and please can they take advantage of PAS, there has to be extensive proof — house deeds, car licence and so on — that they really want to live as well as die there.
This can have sad consequences. I talked to a man who had lived in the state all his life with his wife. When he retired, they sold up and went to live in Hawaii, but after two years she developed cancer. As non-residents they didn’t qualify for PAS.
Since the introduction of the Death with Dignity Act in 1997, remarkably few people have actually ”gone the Oregon way” – only 431 (one death in 1 000). And only one in 10 of those who ask for a prescription use it — they feel secure knowing that they have it as a last resort.
Far greater numbers have an advance directive, setting out the treatments they don’t want, even to prolong life.
PAS is not the only way to go. There’s an organisation called the Hemlock Society that goes in for, in a nurse’s scornful words, ”booze and a plastic bag”. A surprising number of patients simply stop eating and drinking — not a pleasant way to go, but apparently one that upsets families and nurses less than a lethal dose.
Claims that assisted death has impacted badly on palliative care in Oregon were firmly dismissed by the Oregon hospice Association’s chief executive, Ann Jackson, who said Hospice care in the state had doubled since the Act, that Oregon was rated the second-best state in the US for it, and that the only measure on which they did not score highly was palliative care in hospitals — not surprising, as hospice care in Oregon follows the patient and 95% of it happens at home, where people prefer to die.
A survey of Oregon doctors also showed that, since PAS, they have taken more care with pain relief — presumably in the hope of making patients content to stay alive. Of patients who choose assisted suicide, 86% are hospice patients, and the hospices, originally opposed to it, now mostly accept and help with it, though any nurse with conscientious objections can give the patient a ”warm hand transfer” to another.
They also have foster care for some older, sicker people — a useful idea for families that can’t cope.
Many hospice people and their volunteers see PAS as a friendly, reasonable way to end a life ÂÂ- better than being strung up to tubes and monitors in intensive care.
George Eighmey of Compassion and Choice, the body that originally fought for the law and now helps people towards decisions to die, told me of a woman who had had a double mastectomy and made a display of her three or four dozen bras on a clothesline, and of a man who had had bladder trouble who filled a row of potties with petunias and pansies — all part of trying to make illness and even death more homely and bearable.
The legislation is tightly drawn, and efforts to prove it unconstitutional have failed.
Oregon prides itself on being independent: it is the only state that refuses to allow private building on the seashore that might keep people from getting to the beach, and refused to assure Homeland Security, the federal terrorist chasers, that the local police force would cooperate with them. They also have the first oscillating water column for producing wave energy off the west coast and allow skateboarding as a legal form of transport on roads.
”These are the rugged individualists who conquered the west,” says Dr Linda Ganzini, who has done extensive research on assisted dying. Their conviction that people should be able to choose how they die is part of their insistence on patient autonomy, as opposed to meekly obeying the doctor.
It is mostly the strong-minded and competent who achieve the death they have chosen. Patients don’t always choose PAS for intractable pain: men can’t bear the collapse of normal bodily functions and the fact that other people have to cope with them; women are more likely to despair of lives in which the things that gave them joy or satisfaction are now beyond them.
The safeguards also exclude some who might dearly love a planned and dignified death. It is the educated, the competent, those with a decent relationship with a doctor — which usually means a decent relationship with health insurance — who are likely to seek it.
The very poor have Medicaid, which doesn’t pay too well, so not all doctors welcome it. And it is very difficult for the hard-up and erratically employed but not actually on the streets — who make up the 17% of those who have no insurance at all — to raise the required cash to form a satisfactory relationship with the doctor, who has to certify the patient has less than six months to go. This often excludes those with Aids, multiple sclerosis or Alzheimer’s.
Of the European countries that have assisted death, only Holland does not require death to be more or less imminent. Yet if you are in pain and unlikely to die soon, you might ache even more for an ending to it all. The hospitals that are at all religious won’t have anything to do with it, and neither will federal hospitals — their personnel are told that if they even tell patients how they might access PAS, they’ll be fired, though a few supporters of the legislation managed to ensure that it’s only on hospital premises that they aren’t to tell patients about it. The Oregon Health and Science University will take on such patients, the Kaiser Permanente HMOs — like mini health services — are not opposed, but any idea that it’s a breeze to demand an easy death is definitely wide of the mark.
Many religious people remain unalterably opposed (though there hasn’t been any of the violence associated with anti-abortionists).
Assisted death was brought into fierce public debate in 1998 by Terri Schiavo, the Florida woman kept alive in a coma for years after a heart attack. Her husband wanted her artificial feeding and breathing withdrawn, but her mother thought that even if she were never to regain consciousness, her life had value — and many agreed. After a prolonged legal battle, her feeding tube was withdrawn in 2005.
The national organisation of the disabled, Not Dead Yet, thinks any suggestion that lives should be deliberately ended devalues the lives of the disabled, that the law ”deprives the disabled of the benefit of suicide prevention”. Many doctors are also deeply uncomfortable; their instinct is to keep the patient alive.
In Portland I met people who had had contact with PAS. They spoke sadly of dying but did not question the decisions of the deceased. One woman who worked as a volunteer with patients said she had nothing against assisted suicide, but was far more concerned about the people who never, under their system, get good healthcare, who were old or sad or desperately poor and had no one to care for them. That was where they should be putting their efforts.
She’s probably right, but Oregon at least shows the way forward for dealing with the problem that is not brought about by too little healthcare, but almost by too much — the ability to keep people alive long after they would once have served their term. —