Bioethics Discussion Blog: Death with Dignity: Where is the Compassion in the Federal Government?

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Wednesday, October 05, 2005

Death with Dignity: Where is the Compassion in the Federal Government?

Today, the U.S. Supreme Court is taking up the issue of whether it is the federal government or it is the states which can control medical practice and define what or what is not “medical treatment”. The case is that of the U.S. Attorney General vs the State of Oregon. And the object of the discussion is the Oregon’s Death with Dignity Act which allows physicians with licenses to practice in Oregon the right to prescribe a lethal dose of medication to Oregon citizens who are competent and who have a terminal illness and who personally desire to have the opportunity to time their own death by their own hand. The federal government through the drug control laws has decided that the prescribed “controlled” medication cannot be prescribed for the use intended in the Oregon law since these medications can only be prescribed for “medical treatment” and the federal government does not classify assisted-suicide use as a “medical treatment”.

So that those visitors here who would like to know more about this Oregon law, I have copied the FAQ list from the Oregon State government website. The issue, as I see it, is whether it is the federal government can dictate and define how medicine is practiced in any state, rather than, as it has all these many years, being a state responsibility. We saw what seemed like "compassion" (or was it politics>) exuding out of our federal government and our president for Terri Schiavo and her family. But, in fact, Terri was unable to suffer. Now where is the compassion for the Oregon patients who can suffer? .Maurice.




FAQ about Physician-Assisted Suicide


In 1997, Oregon enacted the first and, so far, only physician-assisted suicide law
in the United States. This law (known as the Death with Dignity Act) requires the
Oregon Department of Human Services to collect and analyze data on who
participates in the Act and to issue an annual report. These data are important to
parties on both sides of the issue. Our position is a neutral one, and we offer no
subjective opinions about these questions. We routinely receive inquiries about the
Act. Here are some answers to commonly asked questions.
Q: What is Oregon’s Death with Dignity Act?
A: The Death with Dignity Act permits physicians to write prescriptions for a lethal dosage of medication to people with a terminal illness. This procedure is also known as physician-assisted suicide.
The Death with Dignity Act was a citizens’ initiative passed twice by Oregon voters. The first time was in a general election in November 1994 when it passed by a margin of 51% to 49%. An injunction delayed implementation of the Act until it was lifted on October 27, 1997. In November 1997, a measure was placed on the general election ballot to repeal the Death with Dignity Act. Voters chose to retain the Act by a margin of 60% to 40%.
There is no state “program” for Death with Dignity/physician-assisted suicide.
People interested in participating do not “make application” to the State of Oregon or the Department of Human Services. It is up to qualified patients and licensed physicians to implement the Act on an individual basis. The Act requires the Department of Human Services to collect data on patients who participate each
year in order to determine compliance with the terms of the Act and to issue an annual report.
Q: Who can request physician-assisted suicide?
A: The law states that, in order to participate, a patient must be: 1) 18 years of age
or older, 2) a resident of Oregon, 3) capable of making and communicating health
care decisions for him/herself, and 4) diagnosed with a terminal illness that will lead to death within six (6) months. It is up to the attending physician to determine whether these criteria have been met.
Q: Can someone who doesn’t live in Oregon participate in physician-assisted suicide?
A: No. Only patients who establish that they are residents of Oregon can
participate if they meet certain criteria.
Q: How does a patient demonstrate residency?
A: A patient must provide adequate documentation to the attending physician to verify that s/he is a current resident of Oregon. Documentation might include an Oregon Driver License, a lease agreement or property ownership document showing that the patient rents or owns property in Oregon, an Oregon voter registration, a recent Oregon tax return, etc. It is up to the attending physician to
determine whether or not the patient has adequately established residency.
Q: How long does someone have to be a resident of Oregon to participate in physician-assisted suicide?
A: There is no minimum residency requirement. A patient must simply be able to establish that s/he is currently a bona fide resident of Oregon.
Q: Can a non-resident move to Oregon in order to participate in physician-assisted suicide?
A: There is nothing in the law that prevents someone from doing this. However, the patient must be able to prove to the attending doctor that s/he is currently a bona fide resident of Oregon.
Q: Who can give a patient a prescription for physician-assisted suicide?
A: Patients who meet certain criteria can request a prescription for lethal
medication from a licensed Oregon physician. The physician must be a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) licensed to practice medicine by
the Board of Medical Examiners for the State of Oregon. The physician must also be willing to participate in physician-assisted suicide. Physicians are not required to provide prescriptions to patients. Physician participation in physician-assisted
suicide is voluntary. Additionally, some health care systems (for example, a Catholic hospital or the Veterans Administration) have prohibitions against
practicing physician-assisted suicide that physicians must abide by as terms of their employment.
Q: If a patient’s doctor does not participate in physician-assisted suicide, how can s/he get a prescription?
A: The patient must find another M.D. or D.O. licensed to practice medicine in Oregon who is willing to participate. The Oregon Department of Human Services does not recommend doctors, nor can we provide the names of participating physicians or patients due to the need to protect confidentiality.
Q: If a patient’s primary care doctor is located in another state, can that doctor write a prescription for the patient?
A: No. Only M.D.s or D.O.s licensed to practice medicine by the Board of
Medical Examiners for the State of Oregon can write a valid prescription for lethal medication under the Death with Dignity Act.
Q: How does a patient get a prescription from a participating physician?
A: The patient must meet certain criteria to be able to request to participate in physician-assisted suicide. Then, the following steps must be fulfilled: 1) the
patient must make two oral requests to the attending physician, separated by at least 15 days; 2) the patient must provide a written request to the attending physician, signed in the presence of two witnesses, at least one of whom is not related to the patient; 3) the attending physician and a consulting physician must confirm the patient’s diagnosis and prognosis; 4) the attending physician and a consulting physician must determine whether the patient is capable of making and communicating health care decisions for him/herself; 5) if either physician believes
the patient’s judgment is impaired by a psychiatric or psychological disorder (such
as depression), the patient must be referred for a psychological examination; 6) the attending physician must inform the patient of feasible alternatives to assisted suicide including comfort care, hospice care, and pain control; 7) the attending physician must request, but may not require, the patient to notify their next-of-kin of the prescription request. A patient can rescind a request at any time and in any
manner. The attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
The law makes every attempt to ensure that patients who engage in physicianassisted
suicide are doing so voluntarily, fully informed, and with the ability to
make rational health care decisions for themselves.
Physicians must report all prescriptions for lethal medications to the Department of Human Services, Vital Records. As of 1999, pharmacists must be informed of the prescribed medication’s ultimate use.
Q: What kind of prescription will a patient receive?
A: It is up to the physician to determine the prescription. To date, most patients have received a prescription for an oral dosage of a barbiturate.
Q: What will happen if a physician doesn’t follow the prescribing or reporting requirements of the Act?
A: The Department of Human Services will notify the Board of Medical
Examiners of any deviations. If a formal investigation is warranted by the Board of Medical Examiners, physicians might be subject to disciplinary action.
Q: Must a physician be present at the time the medications are taken?
A: The law does not require the presence of a physician when a patient takes lethal medication. A physician may be present if a patient wishes it, as long as the physician does not administer the medication him/herself.
Q: Can a patient rescind a request for physician-assisted suicide?
A: Yes, a patient can rescind a request at any time and in any manner. The
attending physician will also offer the patient an opportunity to rescind his/her request at the end of the 15-day waiting period following the initial request to participate.
Q: How much does physician-assisted suicide cost?
A: We do not collect cost data. However, direct costs for physician-assisted suicide might include office calls relating to the Death with Dignity request, a psychological consult (if required), and the cost of the prescription.
Q: Will insurance cover the cost of physician-assisted suicide?
A: The Death with Dignity Act does not specify who must pay for the services. Individual insurers determine whether physician-assisted suicide is covered under their policies (just as they do with any other medical procedure). Oregon statute specifies that participation under the Death with Dignity Act is not suicide, so should not affect insurance benefits by that definition. However, federal funding cannot be used for services rendered under Oregon’s Death with Dignity Act. For
instance, the Oregon Medicaid program, which is paid for by federal funding, ensures that charges for physician-assisted suicide services are paid only with state funds.
Q: Can a patient’s family members request physician-assisted suicide on behalf of the patient (for example, in cases where the patient is comatose)?
A: No. The law requires that the patient ask to participate voluntarily on his or her own behalf.
Q: Are euthanasia and physician-assisted suicide the same thing?
A: No. They are two legally distinct procedures for hastening death. In
euthanasia, a doctor injects a patient with a lethal dosage of medication. In physician-assisted suicide, a physician prescribes a lethal dose of medication to a patient, but the patient – not the doctor – administers the medication. Euthanasia is illegal in every state in the union, including Oregon. Physician-assisted suicide has been legal in Oregon since November 1997. Oregon is the only state in the Unionthat has legalized physician-assisted suicide.
Q: What information is available on Oregon’s Death with Dignity website?
A: You can find links to all our annual reports, forms, legislation, rules, press releases and other articles. The annual reports themselves contain an historical background of the Act, a description of the laws pertaining to physician-assisted suicide in Oregon, how data is reported, collected and analyzed, a summary of the year’s results, and tables that outline the participant demographics and disease
characteristics. The Department of Human Services does not collect some
information (such as religious affiliation of participants or cost of the physicianassisted suicide procedure); other information is strictly confidential (such as names of participating patients and physicians).
Q: What is the Department of Human Services’ opinion of physician-assisted
suicide? Does it encourage people to hasten their deaths? Should this law have been passed? What are the pros and cons of physician-assisted suicide?
A: The Death with Dignity Act was a citizen’s initiative, enacted because a majority of voting Oregonians believed that persons afflicted with certain terminal
illnesses should have the legal right to hasten death. The role of the Department of Human Services is to collect and analyze data annually on physician-assisted suicide participation in Oregon. These data are important to parties on both sides of the issue. Our position is a neutral one, and we offer no subjective opinions about these questions.
Q: What is the status of the federal lawsuit against Oregon’s Death with Dignity law?
A: November 6, 2001: U.S. Attorney General John Ashcroft issues a directive which states, in part, that prescribing, dispensing or administering federally controlled substances to assist suicide violates the Controlled Substances Act
(CSA). This new interpretation of the CSA allows the federal Drug Enforcement Agency (DEA) to pursue action to revoke prescription-writing privileges and to pursue federal criminal prosecution of participating Oregon physicians. November 7, 2001: Oregon Attorney General Hardy Myers files suit in U.S.
District Court for a temporary restraining order and preliminary injunction. November 8, 2001: U.S. District Court Judge Robert Jones issues 10-day stay barring implementation of Ashcroft’s order.
November 20, 2001: Judge Jones issues a temporary restraining order against Ashcroft's ruling pending a new hearing.
January 22, 2002: Oregon Attorney General Hardy Myers files a motion for summary judgment.
April 17, 2002: U.S. District Court Judge Robert Jones upholds the Death with Dignity Act. Permanent injunction is filed.
September 23, 2002: Attorney General Ashcroft files an appeal, asking the 9th U.S. Circuit Court of Appeals to overturn the District Court's ruling. May 26, 2004: a three-judge panel upholds Judge Jones’ ruling.
July 13, 2004: Ashcroft files an appeal requesting that the 9th U.S. Circuit Court of Appeals rehear his previous motion with an 11-judge panel.
August 13, 2004: 9th U.S. District Court of Appeals denies Ashcroft’s request. November 9, 2004: Ashcroft appeals the case to the U.S. Supreme Court. February 22, 2005: U.S. Supreme Court agrees to hear the appeal.
Present: Arguments will be held during the U.S. Supreme Court's next term.
At this time, Oregon's law remains in effect.
Further information on the case of the State of Oregon v. John Ashcroft, et al. can
be found at the Department of Justice’s Physician-Assisted Suicide website
http://www.doj.state.or.us/11072001.htm
Q: Where can I find a copy of the statutes and administrative rules governing the
Death with Dignity Act?
A: The statutes can be found at http://egov.oregon.gov/DHS/ph/pas/ors.shtml and
the administrative rules are at http://egov.oregon.gov/DHS/ph/pas/oars.shtml
Q: Where can I find the forms used for Death with Dignity?
A: http://egov.oregon.gov/DHS/ph/pas/pasforms.shtml
Revised 5/23/05

4 Comments:

At Thursday, October 06, 2005 8:41:00 AM, Anonymous Bob Koepp said...

How is prescribing lethal agents so a patient can kill him/herself providing "medical treatment?" Is a non-physician who provides lethal agents for this same purpopse practicing medicine without a license?

What we are witnessing is the use (i.e., abuse) of medicine as a cover for social-political agendas -- with physicians as willing particpants. How unprofessional; how shameful.

 
At Thursday, October 06, 2005 10:00:00 PM, Blogger Maurice Bernstein, M.D. said...

Maybe the correct word (better than "treatment") which would be more realistic regarding what medical practice is all about would be medical "care". "Medical care" would include specific therapy for the diagnosed illness as well as all of the other ways physicians should care for their patients: providing the psychologic and spiritual support and helping to arrange social support and whatever else is necessary to provide essential comfort care. Providing the patient with the ability to have control over when the suffering from their illness should be ended is all part of the physician's medical care of the patient and it is this care for these needs of the patient, comfort care, which some physicians and the voters of Oregon felt was part of the practice of medicine. ..Maurice.

 
At Friday, October 07, 2005 11:30:00 AM, Anonymous Bob Koepp said...

Maurice -
How about putting a patient on a morphine drip, with control of the drip in the patient's hands? Frankly, I think this is how pain control should be accomplished in quite a variety of cases, not just when patients are terminal, or contemplating exiting this world, but much more generally. Or would that relinquish too much "control" to be acceptable to physicians?

p.s. I'm addressing the medical ethical issues, so I've ignored the question of whether the goverment would allow patients this much control.

 
At Friday, October 07, 2005 9:50:00 PM, Blogger Maurice Bernstein, M.D. said...

Bob, the use of the PCA (patient controlled administration) pump for IV morphine administration has been standard practice for years. The pump is set by physician orders to the nurse so that the patient can by pressing a button deliver morphine into the patient's vein to provide relief whenever the patient experiences pain, rather than ringing for a nurse and waiting till she/he administers the morphine. The pump setting sets limits to the dose and intervals and the settings are reevaluated and reset depending on the therapeutic response.

To those patients wanting to use morphine to cause a quick and painless exit, if morphine was made available in a sufficient dose in a syringe, the patient could be instructed how to administer it directly into a vein. Generally, there would be no problem if the dose was sufficient.

With regard to "relinquishing control", I don't think that physicians, these days where ethics and popular opinion seems to be stressing patient autonomy drug company ads to the public are stressing a kind of self-diagnosis and therapy,would find self-management by the patient to be disturbing or indeed unusual. After all, physicians write prescriptions and order tests but non-compliance or self-medication is a common occurance among many patients.
..Maurice.

 

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