Physician-assisted suicide: reflections on Oregon's first case.

• Author: Hendin, Herbert

In November 1997, Oregon became the only state to legalize physician-assisted suicide.(1) Five months later, a task force of health care professionals organized by the Center for Ethics of the Oregon Health Sciences University ("OHSU") issued a guidebook for health care providers "designed to be a comprehensive reference book on all aspects of putting the Act into practice."(2) In March 1998, the media reported news of what were said to be the first cases of legally sanctioned physician-assisted suicide in the state. The first case reported--for which there are some limited details--provides a clinical focus to view the new law and the guidebook's recommendations.

The First Case

Our knowledge of the case is from newspaper reports which conveyed information provided by the staff of Compassion in Dying, a Portland based advocacy group that supported passage of the Oregon legislation. Additional information about the patient comes from anonymous interviews given to selected members of the media by the physician who prescribed the medication. On the day after the patient's death, Compassion in Dying held a news conference in which the patient (referred to here as Mrs. A) was described as being in her mid-80s with metastatic breast cancer, and in a hospice program. The conference featured excerpts from an edited audiotape in which Mrs. A said of her impending death "I'm looking forward to it.... I will be relieved of all the stress I have."(3) The tape was said to have been made two days before her assisted suicide.

Mrs. A's own physician had not been willing to assist in her suicide for reasons that were not specified.(4) A second physician also refused on the grounds that Mrs. A was depressed.(5) Mrs. A's husband called Compassion in Dying and was referred to a doctor willing to participate.(6)

Peter Goodwin, medical director of Compassion in Dying, said that he had two lengthy telephone conversations with Mrs. A at the time of the referral and also spoke by phone to her son and daughter.(7) He described Mrs. A as "rational, determined and steadfast"(8) and called "questionable" the opinion of the physician who described her as having a depression that was affecting her desire to die.(9) Goodwin felt Mrs. A was "frustrated and crying because she was feeling powerless."(10) He said she had been doing aerobic exercises up until two weeks before she contacted him, but told him she could not do them anymore.(11) She was also unable to continue to garden which had been one of her favorite activities.(12) He stated she was not bedridden, was not in great pain, and still looked after her own house.(13) Goodwin said the "quality of her life was just disappearing" and he thought it prudent to act quickly before Mrs. A lost the capacity to make decisions for herself."(14) He said she was "going downhill rapidly.... She could have had a stroke tomorrow and lost her opportunity to die in the way that she wanted."(15)

Goodwin referred Mrs. A to a physician who would assist in her suicide.(16) That physician referred her to a specialist (of an unspecified specialty) and a psychiatrist, both of whom determined she met the qualifications for physician-assisted suicide under the Oregon law.(17) Although the psychiatrist met Mrs. A only once, Goodwin indicated that the visit was lengthy.(18)

The physician who prescribed the medication gave an anonymous interview to Oregon Public Broadcasting in which he described his participation as an "extremely moving experience for me."(19) In an interview with a reporter from The Oregonian, he stated that he was struck by Mrs. A's tenacity and determination. "It was like talking to a locomotive. It was like talking to Superman when he's going after a train."(20)

That physician, who had met Mrs. A two and one-half weeks before she died, described her as having been in greater physical distress than described by Dr. Goodwin. The physician said that she "had battled breast cancer for more than 20 years, and that the cancer had spread to her lungs, causing pain and making breathing difficult."(21) He said that the problem for him "was not fulfilling his responsibilities to the patient under the law but rather finding a pharmacist"(22) to dispense the necessary drugs. Eventually he found a pharmacist. The physician was with Mrs. A and members of her family when she died.(23) The physician followed a protocol devised by Compassion in Dying which included an anti-nausea medication which Mrs. A had taken before he arrived.(24) She then took a mixture of barbiturates (nine grams)(25) and syrup followed by a glass of brandy. She is said to have died within thirty minutes.(26)

The promotional quality of the news conference featuring Mrs. A's taped remarks offended some, including the patient's family members who had not anticipated that these remarks and the story would be made public so soon after Mrs. A's death. Following the announcement of what was thought to be the first legal assisted suicide in Oregon, it was reported and confirmed that since the Oregon law had gone into effect the Hemlock Society of Oregon had helped arrange an even earlier assisted suicide for a cancer patient. The date of that assisted suicide is unknown and at the family's request no details were made available.(27)

The case of Mrs. A is presented by Compassion in Dying as a model of how well the Oregon law works. Yet even with the limited details supplied by Compassion in Dying and the prescribing physician there are disturbing questions raised by the case. The physicians who evaluated Mrs. A offered two contradictory sets of opinions about the appropriateness of her decision. As the decision-making process progressed, there was no mechanism provided by law to resolve the disagreement between the physicians, such as an ethics committee to hear the facts of the case and make recommendations. Instead, the opinions of the two doctors who did not support the patient's decision--one of whom knew her for some time and the other who considered her depressed were essentially ignored. The patient's husband simply contacted Compassion in Dying to find someone who would agree to assist in the suicide of Mrs. A. The medical director of Compassion in Dying, Dr. Goodwin, concluded from a phone conversation with Mrs. A that she was not depressed and that her decision was appropriate. He referred her to a physician who would be willing to help her. That doctor agreed to assist in her suicide and the patient was then referred to a second physician and a psychiatrist, both of whom supported Dr. Goodwin's opinion. As Barbara Coombs Lee, the director of Compassion in Dying stated, "If I get rebuffed by one doctor, I can go to another."(28)

Patients, of course, have the right to obtain second opinions and to seek out physicians who will provide the therapies they choose. In this case, however, the medical opinions should be voiced to facilitate an understanding of the complicated factors involved, which are apparently convincing to some physicians and dismissed by others. Were either Mrs. A's physician or the second physician who diagnosed her as depressed consulted by the physician who eventually assisted in the suicide or did he simply rely on a conversation that Dr. Goodwin had with that physician?

No information is provided to indicate that the physicians recommended by Compassion in Dying were trying to find any feasible alternatives to suicide. In the taped interview with Mrs. A, her physician told her that it is important she understand that there are other choices she could make. He then listed these for her and in three sentences covered hospice support, chemotherapy, and hormonal therapy.

Doctor: There is, of course, all sorts of hospice support that is available to you. There is, of course, chemotherapy that is available that may or may not have any effect, not in curing your cancer, but perhaps in lengthening your life to some extent. And there is also available a hormone which you were offered before by the oncologist--tamoxifen--which is not really chemotherapy but would have some possibility of slowing or stopping the course of the diseases for some period of time. Patient: Yes, I don't want to take that. Doctor: All right, OK, that's pretty much what you need to understand.(29) The physician's awareness that she has seen other physicians and is in a hospice program is not justification for such a cursory approach. During the taped remarks, Mrs. A expressed concern about being artificially fed, a concern that suggests greater vulnerability and uncertainty about her course of action than the physician perceived. He did not assure her that this need not happen in any case. He ignored the remark and instead asked a question designed to elicit a response about her desire to die.(30) Nor did Mrs. A's family raise any questions as to whether anything could be done to cause her to be less eager to end her life. Certainly the reasons given by Dr. Goodwin for haste in effectuating her death are not persuasive.

Mrs. A is not the first physician-assisted suicide case presented by Compassion in Dying to the news media. The organization presented another "model" case that took place before the Oregon law was passed. Before the death, they invited a New York Times reporter to cover the story. The reporter's article titled There Is No Such Thing as a Simple Suicide stated that after her initial request the patient had become hesitant but felt pressured not to change her mind by her mother, her doctor, a friend, and a Compassion in Dying representative. At the end she complains that "everyone is ganging up on me, pressuring me."(31)

Basic Features of the Law

Many of the problems raised by the case of Mrs. A are inherent in the Oregon law. Under this law when a patient requests assisted suicide the physician must determine that the patient is: suffering from a disease that the physician believes will end his or her life within six...