September 3, 2015
Many advocates of a California law allowing doctor-assisted suicide for terminally ill individuals claim that Oregon’s law offers a suitable model. But there are serious problems with the legislation in Oregon and many documented cases of abuse.
I have evaluated and treated thousands of patients who wanted to end their life. A request to die is nearly always a cry for help. Among terminally ill individuals, this request is associated with depression in 59% of cases. And yet, alarmingly, in Oregon less than 5% of individuals who have died by assisted suicide were ever referred for psychiatric consultation to rule out the most common causes of suicidal thinking. Consider the case of Oregonian Michael Freeland, a man with a 43-year history of intermittent depression and suicide attempts prior to his diagnosed medical illness. The doctor who prescribed him the deadly drug did not deem it necessary to refer him for psychiatric consultation. The proposed law in California likewise does not require psychiatric screening.
We’ve seen in Oregon the problem of doctor-shopping, and cases of individuals being pressured by family members. Consider the case of 85-year-old Kate Cheney: her physician and a consulting psychiatrist declined to prescribe the life-ending medication, judging that she lacked capacity due to her dementia, and documenting that the patient’s daughter appeared “somewhat coercive”. Nevertheless, a managed care insurance company found her another doctor who did prescribe the lethal drug. The Oregon Health Division has publicly stated that it has no resources and no authority to monitor or investigate such reported cases of abuse.
Since very few practicing physicians are willing to participate in writing these prescriptions, where it is legalized doctor assisted death becomes a marginalized cottage industry: in Oregon a small number of physicians write a disproportionately large number of the prescriptions. Consider the case of the first woman to die by assisted suicide in Oregon: her physician and a second consulting doctor both refused to end her life because they judged that her request was motivated by untreated clinical depression. The assisted suicide advocacy group Compassion and Choices got involved and referred the woman to their preferred doctor who provided the deadly drug.
Despite the inadequate system of monitoring and reporting in Oregon, the data we do have paints a distressing picture. After suicide rates had declined in the 1990s, they rose dramatically in Oregon between 2000 and 2010, in the years following the legalization of assisted suicide in 1997. By 2010 suicide rates were 35% higher in Oregon than the national average. A rigorous study by David Albert Jones of Oxford University to be published next month controls for other factors that could account for this rise: this research demonstrates that the permissive assisted suicide laws have led to at least a 6% rise in overall suicide rates in Washington & Oregon.
Suicide is among the health-related behaviors that tend to spread from person-to-person through social networks—up to three degrees of separation. We know also that publicized cases lead to clusters of copycat cases. A Swiss study in 2003, for example, indicated evidence for suicide contagion following media reports of doctor-assisted suicide. Furthermore, the law itself is a teacher. These laws communicate the message that under especially difficult circumstances, some lives are not worth living. This message will be heard not only by those with a terminal illness, but by any person struggling with the temptation to end his or her own life.
The Oregon law permitting physician-assisted suicide does not offer a good model for California to follow.
Aaron Kheriaty, M.D., is associate professor of psychiatry and director of the Medical Ethics Program at UC Irvine School of Medicine.