History of the DWDA

The Oregon 'Death with Dignity Act, a citizens' initiative, was first passed by Oregon voters in November 1994 by a margin of 51% in favour - 49% opposed. The immediate implementation of the Act was delayed by a legal injunction (lifted October 27, 1997 after multiple legal proceedings), but Oregon voters reaffirmed the Act in the November 4, 1997 election by a margin of 60% to 40%. [In 2001 John Ashcroft, the Attorney General issued a directive saying doctors who prescrived lethal drugs under Oregon lay could face federal sanctions and prosecution under the Controlled Substances Act, but this directive was overruled by the US Court of Appeals - who stated that Ashcroft had overstepped his authority.]

What the DWDA allows/requires

The DWDA allows physician assisted suicide (but specifically prohibits euthanasia).

The law requires that the patient:

• be an adult;
• be "capable";
• be an Oregon resident;
• have a terminal illness with less than six months to live;
• voluntarily request a prescription for lethal drugs.

The request must be both verbal and in writing, signed and dated by the patient and witnessed by a least two individuals (not to include the attending physician). Patient must reiterate oral request at least 15 days after making initial request.

The attending physician has the following responsibilities:

• determine whether the patient has a terminal illness, is capable, and has made the request voluntarily;
• inform the patient of his/her diagnosis and prognosis, the risks and probable result of taking the prescribed medication, and the alternatives, including comfort care, hospice care and pain control;
• refer the patient to a consulting physician for confirmation of the diagnosis and determination that the patient is capable and acting voluntarily;
• refer the patient for counselling if, in the opinion of either the attending physician or the consulting physician the patient may be suffering from any mental disorder, including depression, causing impaired judgment;
• request that the patient notify next of kin (the patient does not have to comply); and
• offer the patient the opportunity to rescind the request at any time.

Reporting requirements:

The Oregon Health Division (OHD) (now called the Oregon Department of Human Services (DHS)) is required to collect information, review a sample of cases and publish a yearly statistical report.

Since DWDA went into effect in 1997, six official reports have been published. However, due to major flaws in the law and the state's reporting system, lack of accurate information is a crucial problem:

The only physicians interviewed for the official reports are those who prescribed lethal drug doses for patients. [OHD 2nd Year Report, p.7, DHS Report, 3/10/04, p.9]

According to OHD official Dr. Katrina Hedberg, the division has to rely on the word of doctors who prescribed the drugs. [Oregonian, 2/24/00]

Referring to physicians' reports, the OHD admitted: 'For that matter, the entire account could have been a cock-and-bull story. We assume, however, that physicians were their usual careful and accurate selves.' [OHD,CD Summary,3/16/99,p2]

The OHD has no regulatory authority or resources to ensure compliance with reporting requirements. [American Medical News, 9/7/98]

The law contains no penalties for doctors who do not report prescribing lethal doses for the purpose of suicide.

This means that actual numbers of deaths, complications and those who had dementia, depression, felt a burden, were not terminally ill, had inadequate pain control etc may be significantly underestimated.

How DWDA has worked out in practice: Six years of official reports

Assisted suicide deaths reported during the first six years

Official Reports: 171
Actual number: Unknown

The latest annual report indicates that reported assisted-suicide deaths have increased by more than 250% since the first year of legal assisted suicide in Oregon. [American Medical News, 4/5/04] The number of deaths could be far higher.

Complications occurring during assisted suicide

Official Reports: 7 (instances of 'regurgitation')
Actual Number: Unknown

Prescribing doctors don't need to be present when patients take the lethal medication. [DHS Report, 3/6/03, p. 9] Since physicians who prescribe the lethal drugs for assisted suicide are present at fewer than 30% of reported deaths, they may not know about complications. [DHS Report, 3/10/04, p. 9]

Complications found in news reports were not included in official reports.

Speaking to a small group at Portland Community College, pro-assisted suicide attorney Cynthia Barrett described a botched assisted suicide. 'The man was at home. There was no doctor there,' she said. 'After he took it [the lethal dose], he began to have some physical symptoms. The symptoms were hard for his wife to handle. Well, she called 911. The guy ended up being taken by 911 to a local Portland hospital. Revived. In the middle of it. And taken to a local nursing facility. I don't know if he went back home. He died shortly - some….period of time after that…'

Assisted suicide deaths of patients with dementia

Official Reports: 0
Actual Number: Unknown

Assisted suicide death of depressed patients

Official Reports: 0
Actual Number: Unknown

The percentage of patients who were referred for counselling before receiving prescriptions for assisted suicide declined to only 5% during the sixth year. [American Medical News, 4/5/04]

The first known legal assisted suicide was that of a woman in her mid-80s who had been battling breast cancer for twenty-two years. Two doctors, including her own physician who believed that her request was due to depression, refused to prescribe the lethal drugs.

But Dr. Peter Goodwin, medical director of the assisted-suicide group Compassion in Dying (CID), determined that she was an 'appropriate candidate' for death and referred her to a doctor who provided the lethal prescription. [Oregonian, 3/26/98 and Los Angeles Times, 3/26/98]

Patients who received lethal dose more that 6 months before death

Official Reports: 2 or 4
Actual Number: Unknown

Lethal prescriptions under the 'Death with Dignity Act' are supposed to be limited to patients who have a life expectancy of six months or less. [ORS 127.800 §12; 127.815 §a] However, in the first two years of the law's implementation, at least one lethal dose was prescribed more than 8 months before the patient took it. [NEJM, 2/24/00, p. 599]

The sixth annual report noted that 2 patients who received prescriptions in 2002 and another who received the prescription in 2001 died from the lethal drugs in 2003. [DHS Report, 3/10/04, p. 11]

The OHD is not authorized to investigate how physicians determine their patients' diagnoses or life expectancies. [Hastings Center Report, Jan.-Feb. 2000, p. 4.]

First physician asked agreed to write prescription

Official Reports: 27 (41%) in first three years
Actual number: Unknown

'Many patients who sought assistance with suicide had to ask more than one physician for a prescription for lethal medication.' [NEJM, 2/24/00, p. 603] Patients and their families can 'doctor shop' until a willing physician is found.

If a physician opposes assisted suicide or believes the patient does not qualify under the law, Compassion in Dying (CID) may arrange the death. According to Dr. Peter Goodwin, CID's medical director, about 75% of those who die using Oregon's assisted suicide law do so with CID's assistance. [Goodwin speech audiotape, Hemlock Society Conference, 1/11/03]

Shortest length of relationship between patients and prescribing physicians

Official Reports: Less than 1 week
Actual length: Unknown

Although at least 2 weeks must elapse between the first and last requests for the lethal dose, [ORS 127.840 §3.08] the physician who prescribes the drugs for assisted suicide need not be the same physician to whom the first request was made.

For the 3rd through the 6th years, the doctor-patient relationship in some assisted suicide cases was under one week. [DHS Report, 3/10/04, p. 11] Thus, either some physicians are not complying with the 2 week requirement or they stepped in to write an assisted-suicide prescription after other physician(s) refused.

Reasons for requesting PAS

Fear of inadequate pain control:* 37 (22%)
Actual number: Unknown

Fear of being a burden: 60 (35%)
Actual number: Unknown

Financial concerns:** 4 (2%)
Actual number: Unknown

* 46% of patients for whom substantive interventions were made changed their minds about assisted suicide (as opposed to 15% of those for whom no substantive interventions were made) [The New England Journal of Medicine, Volume 342, Number 8, p557]

** Oregon's Medicaid program pays for assisted suicide but does not pay for many other medical interventions that patients need and want. [Oregonian, 4/26/99]