Oregon’s experiment, which is limited to assistance to suicide, raises a particular concern as there was no witness known to be present in nearly half the cases in which the lethal poison is ingested.
It may have been administered to them by a family member or other person under duress, surreptitiously or violently. The design of this assisted suicide scheme means that we can never know.
What we do know is that assistance to suicide is being requested more for existential reasons, including feeling a burden on family and friends (53.4% of cases in 2020) than because of any concern about inadequate pain control (mentioned by 27.4% of people overall).
Oregon’s Dying With Dignity Act which allows medical practitioners to prescribe lethal drugs to a person to use to commit suicide came into force on 27 October 1997.
Oregon publishes annual reports on the operation of the Dying With Dignity Act. Although the data is limited, a careful analysis of the 23 annual reports published to date reveals significant issues with the practice of physician assisted suicide in Oregon.
Increase in number of deaths
The number of deaths from ingesting lethal substances prescribed under Oregon’s Death With Dignity Act reached 245 in 2020 continuing a steady rise at an average growth of 15% per annum. Assistance to suicide accounted for 1 in 164 of all deaths deaths in Oregon in 2020 - up 20% on 2019.
Pain is not a major issue but “being a burden” is
The Oregon annual reports indicate that pain is not a major issue for those requesting physician assisted suicide. Just over one in four (27.4%) of those who have died from ingesting a lethal dose of medication since 1997 mentioned a concern about pain control (they were not necessarily experiencing pain) as a reason for requesting assisted suicide.
However, in 2020 nearly twice that number (53.1%) cited concerns about being a “Burden on family, friends/caregivers”.
Mental health: No adequate screening
Research by Linda Ganzini has established that one in six people who died under Oregon’s law had clinical depression. Depression is supposed to be screened for under the Act.
However, in 2019 only 1 out of 191 (0.52%) of those who died under the Oregon law were referred by the prescribing doctor for a psychiatric evaluation before writing a script for a lethal substance.
Over the 23 years of legalised assistance to suicide it is likely that around 250 people with clinical depression were prescribed and took a lethal poison without being referred for a psychiatric evaluation.
Of those who died from ingesting a lethal dose of medication in 2019, more than one in fourteen (7.4%) mentioned the “financial implications of treatment” as a consideration.
In two notorious cases, those of Barbara Wagner and Randy Stroup, the Oregon Health Plan informed a patient by letter that the particular cancer treatment recommended by their physicians was not covered by the Plan but that the cost of a lethal prescription to end their life would be covered.
The misleading notion of a rapid and peaceful death
The lethal drugs prescribed for assisted suicide do not always result in a swift and peaceful death.
In 2020 there were five cases of complications out of 72 (6.94%) of those for whom information about the circumstances of their deaths is available. This included one case of seizures and 3 cases of difficulty ingesting or regurgitating the poison. In 2019 one in ten (9.84%) either had difficulty ingesting or regurgitated the lethal dose (2) or had other complications (4). In 2018 nearly one in eight (12.12%) of those for whom information about the circumstances of their deaths (or failure to die) is available either had difficulty ingesting or regurgitated the lethal dose (3) or had other unspecified complications (4). One person failed to die and regained consciousness. In 2017 two people had seizures after ingesting the drugs.
The interval from ingestion of lethal drugs to unconsciousness has been as long as four hours (in 2017). In 2019 one person took as long as 90 minutes from ingestion of lethal drugs to unconsciousness.
The time from ingestion to death has been as long as 104 hours (4 days and 8 hours). One person in 2019 took nearly two day (47 hours) to die. In 2020 one person took 8 hours to die and another two people took more than 6 hours to die.
Eight people have regained consciousness after ingesting the lethal medication, including one patient in 2010 who regained consciousness 88 hours (3 days 16 hours) after ingesting the medication, subsequently dying from the underlying illness three months later.
The Death With Dignity Act provides that before prescribing a lethal substance a doctor must first determine whether a person has a “terminal disease”. This is defined as “an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within six months”.
However, 4% of those who have died from ingesting the lethal substance outlived the six month prognosis – some by several years.
In 2019 one person ingested lethal medication 1503 days (4 years and 4 1/2 months) after the initial request for the lethal prescription was made. In 2020 one person ingested the prescribed poison 1080 days (2 years 11 ½ months). Evidently in these cases the prognosis was wildly inaccurate.
This also means that any assessment of competence made at the time of prescribing the lethal substance is well out of date - the person may well have become incompetent to make a decision to ingest the lethal substance for the purpose of causing their own death.
Not a terminal illness
There have been a total of 18 people for whom the “underlying illness” has been listed as “Endocrine/metabolic disease [e.g., diabetes]”. There were 5 people in this category in 2020 – representing 2% of all cases.
Arthritis, arteritis, stenosis and sclerosis (none of which are usually terminal illnesses) have also been recorded as the underlying illness justifying assisted suicide, as well as in 2019 "complications from a fall" (a very imprecise statement of a medical condition). This suggests that even the central requirement that an illness be terminal may not be strictly applied.
Short relationship with attending physicians
The Oregon statute specifies that lethal prescriptions only be written by a person’s “attending physician” who is defined as “the physician who has primary responsibility for the care of the patient and treatment of the patient's terminal disease.”
The data indicates that in some cases doctors have had a relationship with the patient of less than one week’s duration and that in 2020, in half the cases the doctor-patient relationship was of 8 weeks duration or less.
Same day death on request
Prior to 1 Jan 2020, the Oregon law required a period of 15 days between a first request for a lethal prescription and the supply of the lethal dose. Now an exemption from this requirement can be claimed if the attending physician (who may have just met the person and who is not required to have any expertise in the person’s condition) states that the person is reasonably expected to live fewer than 15 days from the first request.
Doctors claimed this exemption for 75 people in 2020 (over 30% of deaths) The length of time from first request to death by ingestion of the lethal poison is reported to range from 0 days to 1080 days in 2020 – so some people asked for assistance to suicide and suicided with the lethal poison on the very same day.
This gives no time to explore other responses to a request for assistance to suicide before a person is dead by prescribed lethal poison.
Who administers the lethal poison?
In 2020 a physician or other healthcare provider was known to be present at the time the person died after the lethal substance was ingested in just over one third of all cases. A "volunteer" is reported as present at the time of death in a further one in six cases.
In nearly one in two cases (47%) there is therefore no evidence that the person took the lethal substance voluntarily. It may well have been administered to them by a family member or other person under duress, surreptitiously or violently. We can never know.
Oregon’s 23 year experiment with an assisted suicide law, far from providing a model that other jurisdictions should follow, serves as a warning that such a law cannot guarantee that all deaths from assistance to suicide are either voluntary or peaceful, or limited to those who actually meet the eligibility criteria.