Law and Ethics in Death and Dying – Civil War in 21st Century

1. Law and Ethics in Death and Dying – Civil War in 21st Century 4/6/2006 Hsiu-I Yang

2. Laws and Ethics in Death and Dying • Passive Euthanasia • (Withholding or withdrawing life-supporting system) – Legal and Ethical • Active Euthanasia • (Administering lethal medication or giving deadly prescription)– Illegal and Unethical

3. Passive Euthanasia Karen Quinlan Case Nancy Cruzan Case Terri Schiavo Case

4. Karen Ann Quinlan was the first modern icon of the right-to-die debate. The 21-year-old Quinlan collapsed at a party after swallowing alcohol and the tranquilizer Valium on 14 April 1975. Doctors saved her life, but she suffered brain damage and lapsed into a "persistent vegetative state." (PVS) Her family waged a much-publicized legal battle for the right to remove her life support machinery. They succeeded, but in a final twist, Quinlan kept breathing after the respirator was unplugged. She remained in a coma for almost 10 years in a New Jersey nursing home until her 1985 death. . Then Case of Karen Ann Quinlan

5. On January 11, 1983, she, then 25, lost control of her old car that had no seat belts, was thrown from it and landed face down in a water-filled ditch for at least 15 minuates. Paramedics found her with no vital signs, but they resuscitated her. After about nine months of remaining dormant within a coma, she finally woke up in a PVS. Surgeons inserted a feeding tube for her long-term care. Her husband and parents waited for a more substantial recovery, but eventually, after four years, accepted that there was no hope. In 1987 her parents asked to have Cruzan's feeding tube removed, but the hospital demanded a court order to that effect. . The case of Nancy Cruzan.

6. . • In July 1988, The trial court allowed the parents to discontinue tubal feeding, based on the testimony of a housemate of Cruzan who relayed that Cruzan would not wish to continue her life on artificial support. The attorney general of Missouri appealed the decision to the Missouri Supreme Court. • By the time the Cruzan case reached the Missouri Supreme Court in 1988, that court had recognized a competent person’s right to refuse treatment as part of the doctrine of informed consent. For decisions to be made on behalf of an incompetent patient, however, the court required "clear and convincing" evidence that the patient would have wanted treatment terminated under such circumstances. • The state of Missouri paid for Nancy’s care.  • Nancy’s parents then took Nancy’s case to the U. S. Supreme Court.  Supporting the Cruzan’s petition to disconnect Nancy’s feeding tube were the American Medical Association, the American Academy of Neurology, The American Nurses Association and the Society for the Right to Die.  The American Academy of Neurology argued that “duty” requires doctors to continue treating unconscious patients as long as there is some chance of improvement. . .which Nancy didn’t have.  They concluded that when hope is gone, “duty ends.”

7. . • On June 25, 1990, the United States Supreme Court, in a 5 to 4 vote, affirmed the Missouri Supreme Court ruling in Cruzan v Director, Missouri Department of Health 497 US 261 (1990) • The opinion of the Court states "for purposes of this case, we assume that the United States Constitution would grant a competent person a constitutionally protected right to refuse lifesaving hydration and nutrition" (497 US at 279). (The Court noted that "most state courts have based a right to refuse treatment on the common law right to informed consent ... or on both that right and a constitutional privacy right" 497 US at 262). The Court also held that Missouri was able to require a standard of "clear and convincing evidence" with regard to a person's wishes, and that "the State may properly decline to make judgments about the 'quality' of a particular individual's life and simply assert an unqualified interest in the preservation of human life to be weighed against the constitutionally protected interests of the individual" (497 US at 283). • The Court sent the case back to Missouri courts.

8. . • On December 14, 1990, the Curzans produced that “clear and convincing” evidence to Judge Charles Teel, Jr.  Three close friends of Cruzan came forward with evidence that her wishes expressed when she was competent were that she would want the tube removed. The judge then ruled that Nancy Cruzan could be withdrawn from having chemical nutrition and hydration pumped into her stomach.  • Cruzan's feeding tube was taken out in December 15 1990, 19 members of Operation Rescue, including a nurse, appeared at the hospital to re-insert the feeding tube, but they were arrested. Cruzan died 11 days later on December 26, 1990. • Her father committed suicide in 1996 and her mother died in 1999. Nancy Cruzan had two sisters, Chris and Donna; Chris Cruzan White ran the Cruzan Foundation, a program that assisted others with end-of-life decisions, but closed it in 2004.

9. Afterwards • In 1991, as a result of the Cruzan decision, the federal government enacted the Patient Self-Determination Act, which requires hospitals, nursing facilities, hospices, home health care programs, and health maintenance organizations to inform patients about their right to make forward-looking care and treatment decisions through the use of advance directives. In the years following the Cruzan decision, states enacted medical proxy laws, whereby individuals could designate someone to make medical decisions for them if they become incapacitated, and developed a variety of living wills, legal statements of individuals’ end-of-life care wishes. • The Cruzan legacy was to foster the development of mechanisms for safeguarding the interests of people who become incapacitated at the end of life. Others could avert the tragedy of the Cruzans—and free themselves of some of the fear around end of life. A recent article, however, points to the fact that few people take advantage of the options the case made available to them: only 10 percent have living wills to reflect their wishes regarding end-of-life care, should they become incapacitated[5].

10. The Case of Terri Schiavo • On 25 February 1990, 26-year-old Terri Schiavo suffered severe brain damage when her heart stopped for five minutes. Schiavo spent the following years in rehabilitation centers and nursing homes but never regained higher brain function. • In 1998 her husband, Michael Schiavo, filed a legal petition to have Schiavo's feeding tube removed, saying that his wife had told him before her medical crisis that she would not want to be artificially kept alive in such a situation. • Terri Schiavo's parents, Bob and Mary Schindler, fought this request. A videotape made by her parents. On the tape, Terri Schiavo , propped up in bed, is greeted and kissed by her mother. She is not in the deep, unresponsive sleep of a coma.

11. . • Her eyes are open, and she blinks rapidly but fairly normally. She seems to follow her mother's movements ,Her jaw is slack and her mouth hangs open, but at moments its corners appear to turn up in a faint smile. • The tape demonstrates that she can still think and react. • Florida judge George W. Greer ruled in 2000 that Schiavo was "beyond all doubt" in a persistent vegetative state and that her husband could discontinue life support. • But as legal appeals in the case continued, the case became widely known as some religious groups and pro-life activists began to insist that Schiavo should be kept alive.

12. . • Schiavo's feeding tube was removed in 2003, but reinserted six days later when the Florida legislature passed "Terri's Law," which allowed the state's governor to issue a stay in such cases. • The law was later ruled invalid by the courts. In March of 2005 Schiavo's feeding tube was again removed, and the case became a greater public sensation when the U.S. Congress was called into special emergency session to pass a bill allowing federal courts to review the case, with President George W. Bush flying from Texas to Washington especially to sign the bill into law. • However, federal judges and the U.S. Supreme Court refused to intervene. After two weeks without food and water, Schiavo died of dehydration on 31 March 2005.

13. Afterwards • An autopsy after Schaivo's death showed that Schaivo's brain had shrunk to about half normal size, and that Schaivo was blind. "No amount of therapy or treatment would have regenerated the massive loss of neurons," according to the medical examiner, Dr. Jon Thogmartin. However, the autopsy was unable to pinpoint the cause of Schaivo's collapse in 1990... Schiavo's case was considered to have political implications, as Florida governor Jeb Bush and his brother, U.S. president George W. Bush, both had been elected with the vigorous support of pro-life conservatives... Terri and Michael Schiavo were married on 10 November 1984.

14. Active Euthanasia Dr. Jack Kevorkian. The case of “Diane” and Dr. Timothy Quill. The case of Bob Dent and Dr. Philip Nitschke.

15. The case of Janet Adkins and Dr. Jack Kevorkian. • On June 4, 1990, Janet Adkins, a 54 year old woman with Alzheimer’s disease, deliberately ended her life with the help of Dr. Jack Kevorkian, a retired pathologist in Michigan who had devised a way for a person to self administer a lethal dose of drugs to end life.  Janet’s husband and a friend of hers supported Janet’s decision to end her life rather than, in Janet’s words, “to put my family or myself through the agony of this terrible disease.” Janet Adkins was diagnosed as having Alzheimer’s disease.  Alzheimer’s disease is an organic mental illness, a pre senile dementia.  Janet knew she was slowly and unrelentingly losing her mind.  She may not have been mentally competent, especially in light of her diagnosis. • Alzheimer’s disease is a terrible affliction which commonly lasts for years and only ends at death.  Janet Adkins was not terminally ill; people don’t die of Alzheimer’s dementia.  The question of competency arose.

16. . • KOMO TV, Channel Four in Seattle, focused on the Adkin’s situation.  Eighty percent of those who called in to cast their vote for or against Janet’s “right to die” voted for it.  We must exercise extreme caution to carefully consider what criteria are necessary to assure that terminally or incurably ill persons can receive physician assistance in dying. • Janet Adkins was Dr. Kevorkian’s first patient.  On 12-13-90 Michigan District Judge Gerald McNally listened to a forty minute videotape made of Adkins and Dr. Kevorkian discussing Janet’s fight against her Alzheimer’s disease.  “I’ve had enough,” she said on the tape.  Judge McNally then dismissed the first-degree murder charge against Dr. Jack Kevorkian, the 62 year old retired pathologist and inventor of the “suicide machine” Janet used to end her life.  Janet’s husband, Ronald, said he was relieved that the judge had dismissed the case, saying, “I and the family are very pleased and very grateful for the judge making the decision that he did.” • Since then, Dr. Jack Kevorkian went on to help more than a hundred terminally or incurable patients die.  

17. . • In 1997 the Supreme Court ruled that the Constitution does not give dying people the right to defy a state's law by obtaining a physician to assist them to hasten death. The Court okayed a patient to hasten death if the state within which that patient lives empowers hastening death as a legal option.  In 1999 Dr. Kevorkian was tried, convicted of second degree murder in Michigan for helping a 52-year-old man with Lou Gehrig's disease take a lethal dose of potassium chloride.  It was then and still is legal for a physician to aid a terminally ill person to hasten death in Oregon.  Dr. Kevorkian was sentenced to 10 to 25 years in prison.  He made numerous appealed.  His case arose to the Supreme Court.  Kevorkian argued that "there is a constitutional right to be free of unbearable pain and suffering."  In early October of 2002 the Court declined to hear 1,800 cases appealed to it.  One of those was Kevorkian's.  He is in his mid seventies and has promised not to aid anyone else in dying, yet he is still held in prison even though most Americans now favor legalizing the right of a terminally ill person to receive a physician's aid to hasten death. 

18. The case of “Diane” and Dr. Timothy Quill. • In March 7, 1991, the New England Journal of Medicine printed Dr. Timothy Quill’s article “Death and Dignity: A Case of Individualized Decision Making.”  Dr. Quill is a licensed physician working at the Genesee Hospital in Rochester, New York.  He is also a former director of a hospice program and therefore very familiar with the treatment of dying patients. • “Diane” (a pseudonym) was a 45 year old patient Dr. Quill had treated for eight years.  She was raised in an alcoholic family, had had vaginal cancer as a young woman, and had struggled much of her adult life with depression and her own alcoholism.  She confronted her problems and gradually overcame them.  She had maintained complete abstinence from alcohol for more than three years.  Dr. Quill admired her strong sense of independence and confidence.  “She was an incredibly clear, at times brutally honest, thinker and communicator,” Dr. Quill wrote.

19. . • Diane had been told by her oncologist (Cancer specialist) that she had acute myelomonocytic leukemia, a severe form of the disease that would end in her death within weeks or a few months without treatment.  Treatment would consist of chemotherapy, irradiation, bone marrow transplantation and months of hospitalization.  Diane was “enraged” when the oncologist presumed that she would want treatment and had begun plans to start chemotherapy that very afternoon.  She refused treatment and went home.  After two days of talking with her husband, her college age son, and her psychologist, she kept her decision to refuse treatment. • Dr. Quill talked repeatedly with Diane about her fear of a lingering death or of the  treatment which only had about a 25% chance of giving her a cure.  She said she wanted to “take her life in the least painful way possible.”  Dr. Quill referred her to information available from the Hemlock Society.  Dr. Quill wrote:

20. . • A week later she phoned me with a request for barbiturates for sleep.  Since I knew that this was an essential ingredient in a Hemlock Society suicide, I asked her to come to the office and talk things over.  She was more than willing to protect me by participating in a superficial conversation about her insomnia, but it was important to me to know how she planned to use the drugs and to be sure that she was not in despair or overwhelmed in a way that might color her judgment.  In our discussion, it was apparent that she was having trouble sleeping, but it was also evident that the security of having enough barbiturates available to commit suicide, when and if the time came, would leave her secure enough to live fully and concentrate on the present.  It was clear that she was not despondent and that in fact she was making deep personal connections with her family and close friends.  I made sure that she knew how to use the barbiturates for sleep, and also that she knew the amount needed to commit suicide.  We agreed to meet regularly, and she promised to meet with me before taking her life, to ensure all other avenues had been exhausted.  I wrote the prescription with an uneasy feeling about the boundaries I was exploring spiritual, legal, professional, and personal.  Yet I also felt strongly that I was setting her free to get the most out of the time she had left, and to maintain dignity and control on her own terms until her death.

21. . • Diane lived • “several very intense and important” months with her husband, son, and close friends. [Then] it was clear the end was approaching.  Diane’s immediate future held what she feared most: increasing discomfort, dependence, and hard choices between pain and sedation.  She called her closest friends and asked them to come over and say good-bye, telling them that she would be leaving soon. • She visited Dr. Quill for a last time.  Two days after that visit, her husband called to tell Dr. Quill that Diane had died.  Dr. Quill continued, • She had said her final good-byes to her husband and son that morning, and asked them to leave her alone for an hour.  After an hour, which must have seemed an eternity, they found her on the couch, lying very still and covered by her favorite shawl.  There was no sign of struggle.  She seemed to be at peace.  I wonder whether the image of Diane’s final aloneness will persist in the minds of her family, or if they will remember more the intense, meaningful months they had together before she died.  I wonder whether Diane struggled in that last hour, and whether the Hemlock Society’s way of death by suicide is the most benign.  I wonder why Diane, who gave so much to so many of us, had to be alone for the last hour of her life. • .

22. . • Had Dr. Quill or Diane’s family been with her they could have been charged with “aiding in a suicide,” a felony crime at that time in New York where it happened, and in almost every other state. Dr. Quill wrote his article because he had decided that it was important to tell the public and other doctors that it is right for doctors to help patients to maintain their dignity in dying. • The compassionate and courageous Dr. Quill was one of the physicians who sued the state of New York to overturn the state’s blanket ban on assisting a suicide.  That suit lead to the unanimous conclusions written by Judge Roger J. Minor of the Second Circuit Court of Appeals cited often in this book.

23. The case of Bob Dent and Dr. Philip Nitschke. • On September 22, 1996, Bob Dent, a 66 year old carpenter and ex-pilot, was the first person in the history of the world to receive legal physician aid-in-dying.  His wife of twenty years, Judy, supported his decision to die. Bob lived in the city of Darwin located within the Northern Territory of Australia.  • That May, the Northern Territory’s Legislative Assembly barely passed the Terminally Ill Act by a vote of 13 to 12.  It became effective on July 1, 1996.  The Act enables a qualified terminally ill person to request a physician to administer a lethal drug (euthanasia) or provide it for self-administration (physician aid-in-dying). Bob was diagnosed with prostate cancer in 1991.  Both his testicles had been removed.  He was impotent, had lost 25 kilograms, wore a catheter and a leg beg and required 24-hour care.  He reported, “I cannot even get a hug in case my ribs crack.”  He was taking 30 pills a day, not including morphine which had made him feel even sicker. • Five psychiatrists had refused to certify that he was not suffering a treatable clinical depression.  Finally a nationally renowned psychiatrist from Sydney flew in to evaluate him.  Dr. John Ellard reported that Bob was “an intelligent and sensitive man, fully aware of all the issues concerning him and his illness” and that Bob was not suffering from a depression even though he was physically very weak from his terminal illness and wanting to end his life.

24. . • Bob had found his new-found Buddhist beliefs to give him the solution to his suffering.  He renounced greedy attachment to life.  He learned that “man is born with death in his hand.”  He understood “the unity of life and the elimination of suffering” and believed hastening death was consistent with his beliefs.  At the time of death Bob put Dr. Nitschke at ease by reminding him that this was “an act of love.”  After a simple lunch of a ham sandwich and a glass of stout, he told Dr. Nitschke, “You’re here to do a job; let’s get on with it.” • Dr. Nitschke used a portable lap-top computer connected to a syringe to inject lethal drugs into Bob’s arm.  The computer program required Bob to answer three final questions, the last one being, “In 15 seconds you will receive a lethal injection and die.  Do you wish to proceed?  Yes/No.”  The program could be stopped at any time.  Bob pressed “Yes” and died peacefully within minutes. • The day before he died, Bob dictated this edited “Open Letter to Federal Parliamentarians.”  Here’s some of Bob’s open letter:

25. . • I have no wish for further experimentation by the palliative care people in their efforts to control my pain.  My current program involves taking 30 tablets a day! For months I have been on a roller-coaster of pain made worse by the unwanted side effects of the drugs. Morphine causes constipation - laxatives taken work erratically, often resulting in loss of bowel control in the middle of the night.  I have to have a rubber sheet on my bed, like a child who is not yet toilet-trained.  Other drugs given to enhance the pain-relieving effects of the morphine have caused me to feel suicidal to the point that I would have blown my head off if I had had a gun.I can do little for myself. My red cells are decreased in number and deformed because of the cancer in the bone marrow. This anemia causes shortness of breath and fainting.

26. . • My own pain is made worse by watching my wife suffering as she cares for me; cleaning up after my "accidents" in the middle of the night, and watching my body fade away.  If I were to keep a pet animal in the same condition I am in, I would be prosecuted.  I have always been an active, outgoing person, and being unable to live a normal life causes much mental and psychological pain, which can never be relieved by medication. • I read with increasing horror newspaper stories of Kevin Andrew's attempt to overturn the most compassionate piece of legislation in the world. (Actually, my wife has to read the newspaper stories to me as I can longer focus my eyes.)  If  you disagree with voluntary euthanasia, then don't use it, but don't deny me the right to use it if and when I want to. • Sydney, Australia’s Roman Catholic Archbishop Edward Clancy told a news conference, I was, and still am, deeply ashamed that Australia should be the only country in the world to legalize the killing of an innocent person.  Respect, reverence for human life is a cornerstone of our civilization.  When that goes, our society begins to unravel.Father Gino Cooncetti, a Vatican moral theologian close to Pope John Paul II said, One remains stupefied and horrified by this shocking case of euthanasia that was requested and granted.  No law of the state can justify euthanasia.  This would mean the end of human civilization based on love and justice.Opposition is intense.  Kevin Andrews, who Bob begged “not to attempt to overturn the most compassionate piece of legislation in the world,” introduced to the Australian federal Parliament a bill which abolished the Act. Addressing the entire situation, “THE AGE,” a newspaper in Melbourne, ran an editorial that concluded, • Imperfect though it may be in some respects, the Northern Territory legislation should not be wantonly struck down.  Those - including the Prime Minister, Mr. John Howard - who are inclined to support the proposed veto must explain their qualms in rational and compelling terms.  Lofty rhetoric based on fear or fallacy will not convince Australians who regard their stance as cowardly or callous.

27. Oregon’s "Death With Dignity Act." .

28. . • In 1994, despite court challenges, Oregon voters approved initiative “Measure 16," their “Death With Dignity Act” even though similar initiatives earlier had failed narrowly in Washington and then again in California.  The U.S. Catholic Conference, the National Right to Life and the American Medical Association campaigned mightily against it.  Immediately upon passage, an injunction was placed against the Act by U.S. District Judge Michael R. Hogan.  Janice Elsner, suffering from muscular dystrophy, argued before Judge Hogan that she might use the law in a state of depression, even though she was morally opposed to assisted suicide.  She argued that Oregon’s “Death With Dignity Act” had inadequate safeguards to protect her in case she succumbed to the temptation of hastening death.  Judge Hogan, a Roman Catholic, agreed with Janice and declared Oregon’s “Death With Dignity Act” unconstitutional because it supposedly did not afford adequate protection for a terminally ill person who did not want to hasten death.  One of Elsner's attorneys, Richard Coleson, affiliated with the National Right to Life Committee, tried another argument, asking Hogan to block the implementation of the "Death With Dignity Act" because it allowed only the terminally ill to kill themselves and therefore it stigmatized them as having lives less worth living than everyone else.  Judge Hogan also considered motions to add another terminally ill plaintiff, Troy Thompson, suffering from Lou Gehrig's disease, to the suit to certify it as a class action.  These additional tactics failed. In October 1997, the Ninth U.S. Circuit Court of Appeals overturned Hogan’s ruling forcing him to lift the injunction he had placed against the assisted suicide law.  The Ninth found that the plaintiff Elsner did not have standing to sue because Oregon’s law did not injure her. The Ninth’s decision was appealed to the U.S. Supreme Court which refused to hear it and on October 9, 1997, the Ninth U.S. Circuit Court of Appeals dismissed the suit altogether.

29. . • Another attempt had been made against the implementation of Oregon’s “Death With Dignity Act.”  Oregon’s legislators tinkered with the Oregon State Constitution and thereby forced Oregonians to vote on the issue again.  This time Oregonians voted on whether to repeal the “Death With Dignity Act” they had passed three years earlier.  Pundits predicted that “rejecting the repeal” would confuse the voters.  Oregonians were not confused.  In November 1997, Ballor Measure 51 was placed before the Oregon voters to repeal the "Death With Dignity Act" which they had earlier approved by initiative 50 to 49%.  The repeal was defeated by a 20% margin.  Oregonians thereby approved their “Death With Dignity Act” a second time by an even greater margin than they had the first time!

30. . • As soon as the legislators’ attempt to get the voters to repeal the law and Judge Hogan’s injunction against the Act were cleared, the law was ready for use.  Opponents began still another tactic.  The National Conference of Catholic Bishops contacted Representative Henry Hyde, a Republican from Illinois, to discuss how Oregon’s law might violate federal drug laws.  U.S. Senators Hyde and Orrin Hatch, a Republican from Utah, queried Drug Enforcement Administration (DEA) Administrator Thomas Constantine.  Constantine opined that Oregon’s law violated federal drug laws and decided that the DEA would revoke the prescription privileges of any physician who aided a terminally ill person to hasten death even though an Oregon physician is legally able to do so.  It was peculiar that two Senators so well known for their advocacy of “States Rights” would have sparked such a federal trump of a state law.  States Rights?  Federal Rights?  How about Last Rites? • In June U.S. Attorney General Janet Reno overruled Constantine and declared that the DEA lacks the authority to sanction doctors acting responsibly under Oregon's law. • The day of Reno's announcement, Hyde, chairman of the House Judiciary Committee which later voted to impeach President William Jefferson Clinton, introduced a bill, “The Lethal Drug Abuse Prevention Act of 1998.”  The bill stated, “the dispensing or distribution of controlled substances to assist suicide is not a legitimate medical purpose and should not be construed to be permissible under the Controlled Substances Act.”  Hyde's bill would have broadened the authority of the DEA to set up a medical review board to deny, suspend or revoke a physician's federal drug-prescribing privileges if the doctor prescribed or intended to prescribe drugs to assist in a suicide or euthanasia.  Without being able to prescribe pharmaceuticals, most physicians could not maintain their practice so they would effectively be blocked from assisting a terminally ill Oregonian to hasten death even though it is legal to do so in Oregon.  A federal agency could have blocked Oregon physicians and severely restricted the national debate on this issue.

31. . • The American Medical Association and the National Hospice Organization, staunch opponents of Oregon’s “Death With Dignity Act,” came out against Hyde's bill.  Both groups oppose assisted suicide, but they feared Hyde's bill would discourage the aggressive use of drugs to control pain, anxiety and other symptoms suffered by dying patients.  Hyde's bill, fortunately, died but has lately resurrected itself. • On October 27,1999, the United States House of Representatives passed Hyde's “Lethal Drug Abuse Prevention Act” which would make it a federal crime for doctors to prescribe drugs to help terminally ill patients hasten death.  The bill states that a physician who prescribes controlled substances "for the purpose of causing death" is subject to criminal penalties - 20 years in prison!  Representative Hyde, a long-time champion of states rights, stated, "Oregon decided to change the time-honored professional purpose of medicine and give doctors the option to serve no longer as healing forces, but as social engineers, messengers of death."  He continued his misinformed diatribe, "Doctors are authorized by Oregon law to put down the stethoscope and pick up the poison pill and assist in the execution of their patients."  Obviously Hyde does not understand that Oregon's bill prohibited euthanasia by "execution."  Hyde's current anti-state's rights stance against Oregon's "Death With Dignity Act" was challenged by the United States Department of Justice which, although it opposes physician aid-in-dying, declared that Hyde's bill would "interfere with state policy in a particularly heavy handed way."  Representative David Wu, Oregon Democrat, called Hyde's hypocrisy by saying, "This is a day of shame for the U.S. Congress.  In addiction to overturning Oregon's law, this bill authorizes the Drug Enforcement Administration to second-guess physicians all across America, and its effect on pain management will be devastating.  Few, if any, members of Congress even read the Oregon law they voted to overturn."  This bill assaults Oregon's "Death With Dignity Act" which voters have passed twice and which has proven itself to be working well.  A similar bill was introduced to the U.S. Senate by Don Nickles, Republican from Oklahoma.  When Oregon's senator Wyden threatened to derail Nickles' bill with a time-consuming filibuster, Nickles responded by halting a bill that would send an additional $90 million a year to Oregon counties hit hard by the loss of federal timber revenues. • Oregon's experiment is under siege.  This is "hard-ball" democracy at work.  Supreme Court Chief Justice Rehnquist has stated that  "Our holding permits this debate to continue, as it should in a democratic society."  Hyde and Nickles' bills, if enacted, will quell "this debate" but can't euthanize it!  Unfortunately, if physicians are forced out of aid-in-dying, then other methods will arise, there will be fewer safeguards, and the public safety will be less served.  When physicians aren't allowed to aid in hastening death, then terminally and incurably ill persons will again be left to their own devices.

32. . • In the December 16, 1999 issue of the New England Jounal of Medicine (Vol. 341, No. 25) editor Marcia Angell, M.D. wrote: • If the bill passes both houses of Congress and is signed into law by the President, Oregon will probably challenge the law in the courts. Even many Oregonians who opposed physician-assisted suicide in the state referendums, including the Oregon Medical Association, resent the attempt by Congress to overturn the outcome. The case might then reach the Supreme Court. If it does, one can hope that the justices will remember their commitment to the laboratory of the states. Otherwise, Congress will have done great harm -- to dying patients, both those who want the option of physician-assisted suicide and those who simply want their suffering relieved, and to their physicians, who should be able to offer compassionate care without fear of reprisal.Few Oregonians have used the “Death With Dignity Act” to receive physician aid-in-dying.  The “flood” of terminally ill persons "flowing into Oregon," predicted by opponents to the Act, never materialized.  Oregon physicians will aid only persons who are Oregon residents and who have been clients in their practice for a long enough time to establish a close relationship.  Reader, do not attempt to go to Oregon to get aid-in-dying; it will not work.

33. . • In August 1998, the Oregon Health Division reported: • The average age of the first ten persons to hasten death was 71 years old; • Nine of ten had cancer; the tenth, heart disease; • Nine different doctors wrote the prescriptions; • On average, it took about 40 minutes to die after ingesting the prescription; • No undesirable complications were encountered: and, Doctors complied perfectly with the provisions of the law.

34. . • After three years of legalized physician-assisted suicide Oregon's Health Division issued the following summary:                   The numbers of patients choosing legal PAS has remained small over the                  last three years (6-9/10,000 Oregon deaths per year). While these numbers                  increased from the first year to the second, the third year's findings indicated                  that this increase was not part of a trend. In fact, the numbers of patients                  choosing PAS remained consistent from year two to year three. In each                  year, the proportion of PAS deaths as a subset of deaths due to terminal                  illnesses such as cancers is of the same magnitude as recently estimated by                  Emanuel, et al. and is consistent with numbers from a survey of Oregon                  physicians. Overall, smaller numbers of patients appear to use PAS in                  the U.S. compared to the Netherlands. However, as detailed in                  previous reports, our numbers are based on a reporting system for                  terminally ill patients who legally receive prescriptions for lethal medications,                  and do not include patients and physicians who may act outside the law.                  After the first year's report, the relatively low proportion of married persons                  participating led to concerns that socially isolated patients might be more                  likely to use PAS than patients with better social support. An                  increasing proportion of married participants in years two and three now                  shows that the proportions of PAS patients married, widowed, divorced or                  never married resemble those seen among other Oregonians dying from                  similar diseases. Also, in the second year it was observed that college                  educated patients were 12 times more likely to choose PAS compared to                  patients with less than a high school degree. In this third year we                  considered patients with a post-baccalaureate education separately, and                  found the difference to be even greater. That educated patients are more                  likely to choose PAS is consistent with findings that Oregon patients with at                  least a college degree are more likely to be knowledgeable about                  end-of-life choices. •                   Concern about loss of autonomy and participation in activities that make life                  enjoyable have been consistently important motivating factors in patient                  requests for lethal medication. However, the proportion of patients                  expressing concern about becoming a burden has increased. Consistent                  with previous findings from family interviews, physicians in 2000                  commented that family members were very willing to care for the patients.                  Interestingly, not being a burden was one of only eight end-of-life issues in a                  recent study rated as important by most patients but not most physicians.                 That Oregon PAS patients almost always discussed concern about                  becoming a burden in conjunction with losing autonomy suggests that it                  might be part of patients' ideas about independence. However, a negative                  interpretation of concern about becoming a burden is that patients may feel                  pressured by others into using PAS. No evidence indicates that such                  pressure has been a primary motivating influence among the 70 Oregon                  patients participating to date, but this possibility should be discussed by                  physicians, patients and family members. •                   PAS has become an important element in the national discussion on                  end-of-life care. In 2000, Oregon physicians who prescribed lethal                  medications commented frequently on the role of PAS in this respect. One                  physician was an opponent of PAS, but had decided that as a caregiver it                  was important to support the beliefs of the terminally ill patient. A second                  physician had previously turned down one patient, but the patient assisted in                  2000 "called [the physician] out on his responsibility to provide PAS".                  Another physician wrote a prescription in consultation with a colleague who                  supported the patient's choice but felt uncomfortable providing the                  prescription itself. In each case, the patients were knowledgeable about end                  of life choices and had a complex set of end-of-life concerns contributing to                  their request. While the experiences of these few patients and physicians                  reflect a rarely chosen end-of-life care alternative, they provide an                  important source of insight to inform the national debate on end-of-life car

35. . • Twenty-one patients used legal physician-assisted suicide in 2001, fewer than the 27 who did so in 2000.  The official 2001 report findings include: • In 2001, 44 prescriptions were written for lethal doses of medication, an increase from 24 prescriptions in 1998, 33 in 1999, and 39 in 2000. • Twenty-one patients died after using medication; 19 of the patients obtained their prescription in 2001 and two in 2000. • Fourteen of the 2001 prescription recipients died of their underlying illness and eleven were alive at the end of 2001. • The median age of the 21 patients who took lethal medication in 2001 was 68 years. Thirteen (62 percent) were female, a slight increase from previous years. Twenty (95 percent) were white, eight (38 percent) were college graduates and seven (33 percent) were divorced, compared to 14 percent of other Oregonians who died of similar causes. • Eighteen patients had end-stage cancer. All patients had health insurance. Sixteen (76 percent) were in hospice before death; the other five patients were offered hospice services but declined. • One physician was reported to the Oregon Board of Medical Examiners for submitting an incomplete written consent. • Sixteen (76 percent) patients received secobarbital and five (24 percent) received pentobarbital after Eli Lilly stopped producing secobarbital in May, 2001. During 1998-2000, 67 (96 percent) patients received secobarbital.

36. . • Dr. Katrina Hedberg, deputy state epidemiologist in DHS, reported, "The number of deaths remained small in relation to the 29,541 total Oregon deaths in 2000.  Similar to past years, the data shows that patients were older, highly educated and most had cancer."Oregon leads the nation in many ways.  Forty percent of all terminally ill persons in Oregon die while serviced by hospice.  The rest of the country averages only 14 percent.  In Oregon more people die at home than in hospitals, giving Oregon the lowest in-hospital mortality rate in the country.  Oregon's use of  medical morphine for pain went up by 70 percent.  Oregon is now the leading state in the use of medical morphine despite the number of prescriptions for morphine recently dropping during the DEA's intended attack against physicians who would give aid-in-dying.  Oregon's admission rates to hospices have increased overall by 20 percent.  Oregon's legislature is considering a bill mandating universal hospice coverage to all residents.  Many analysts believe that these numbers were generated, at least in part, because of Oregon's campaign to give its citizens control at end of life decision. • …

37. . • In the Journal of American Medical Association, Vol. 285, No.18, May 9, 2001, "Oregon Physicians' Attitudes About and Experiences With End-of Life Care," the authors studied the effects of the Oregon “Death With Dignity Act” act on clinical practice or physician perspective. • A self-administered questionnaire was mailed in February 1999 to Oregon physicians eligible to prescribe under the act.  Of 3981 eligible physicians, 2641 (66%) returned the questionnaire by August 1999.A total of 791 respondents (30%) reported that they had increased referrals to hospice. Of the 2094 respondents who cared for terminally ill patients, 76% reported that they made efforts to improve their knowledge of the use of pain medications in the terminally ill. Nine hundred forty-nine responding physicians (36%) had been asked by a patient if they were potentially willing to prescribe a lethal medication. Seven percent of all survey participants reported that 1 or more patients became upset after learning the physician's position on assisted suicide, and 2% reported that 1 or more patients left their care after learning the physician's position on assisted suicide. Of the 73 physicians who were willing to write a lethal prescription and who had received a request from a patient, 20 (27%) were not confident they could determine when a patient had less than 6 months to live.The study concluded, "Most Oregon physicians who care for terminally ill patients report that since 1994 they have made efforts to improve their ability to care for these patients and many have had conversations with patients about assisted suicide." Without doubt, terminally ill Oregonians are getting better care at end of life because of Oregon's “Death With Dignity Act.” • filed papers with an appeals court continuing the Bush administration's attack on Oregonian's right to die.

38. . • U.S. District Judge Robert Jones ruled Thursday, April 17th, 2002 that the U.S. Justice Department lacks the authority to overturn Oregon's unique law that allows physician-assisted suicides:  "No provision ... demonstrates or even suggests that Congress intended to delegate to the attorney general ... the authority to decide, as a matter of national policy, a question of such magnitude as whether physician-assisted suicide constitutes a legitimate medical purpose or practice."  The judge faulted U.S. Attorney General John Ashcroft in his decision by saying that Ashcroft "with no advance warning to Oregon ... fired the first shot in the battle between the state of Oregon and the federal government" and that Ashcroft attempted to "stifle an ongoing, earnest and profound debate in the various states concerning physician-assisted suicide."  Judge Jones noted that a recent U.S. Supreme Court ruling encouraged that debate in the states.  "[T]he citizens of Oregon, through their democratic initiative process, have chosen to resolve the moral, legal and ethical debate on physician-assisted suicide for themselves by voting -- not once, but twice -- in favor of the Oregon act."  Oregon, he said maintained the "the proper balance" between the interests of the terminally ill and the government's responsibility to protect them as the Supreme Court had mandated.  Earlier Judge Jones had criticized Ashcroft in court calling the Attorney General's directive an "edict" because Mr. Ashcroft "did not consult with Oregon public officials, provide notice to any of them or to the Oregon general public, or provide opportunity for any public comment anywhere."  Mr. Ashcroft's directive, Judge Jones wrote, was the result of an effort by Congressional leaders "to get through the administrative door what they could not get through the Congressional door, seeking refuge with the newly appointed attorney general whose ideology matched their views."' • Democracy, not theocracy, beliefs or opinions, determines what can and can't be done in this country.  The U.S. has been at war with a country whose leaders ruled by their beliefs rather than by the will of the people.  May Ashcroft learn that his belief-based "edict" is inappropriate in the "great experiment" carried on within the states of these United States.  Remember the conclusion of the U.S. Supreme Court, "Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society." • But on Monday, September 23, 2002 Ashcroft filed papers with an appeals court continuing the Bush administration's attack on Oregonian's right to die.

39. Holland legalizes euthanasia. • On Tuesday, April 10th, 2001 the Dutch Senate overcame three decades of religious and conservative opposition to pass a law giving terminally ill persons the right to suicide and doctors immunity from prosecution for assisting.  Ninety percent of Dutch citizens supported the law to give a human alternative to a painful and undignified death.  The law had already passed with a 46 -28 endorsement by the lower house of parliament in November.  Health Minister Els de Borst and Justice Minister Benk Korthals both applauded the legislation.  Prior to passage of this law doctors who followed the “rules of careful practice” (“zorgvuldig-heidseisen”) were not prosecuted or subjected to disciplinary measures but given the "waiver of prosecution."  To get this waiver doctors had to ensure that the patient's request was voluntary and informed, determine that the patient’s situation entailed unbearable suffering with no prospect of improvement, discuss the situation with another doctor, the patient’s family and the nursing personnel, keep a full written account of the case, and fill out a "certificate of natural death" noting the doctor's assistance in dying.  Holland's euthanasia law put an end to this legal limbo.  Rob Jonquiere, managing director of the Dutch Voluntary Euthansaia Society noted, "This is an important and sensitive decision, and concerns about abuse are unfounded.  Abuse is only possible when there is no legal framework, which is the problem we've resolved today." • A minority of protestors urged, "Trust in God, not the syringe."  Senator Klars Veling, a Christian Union party senator who voted against the legislation, warned, "It is dangerous and unworthy for a civilized society if doctors are allowed to kill."  The Vatican has strongly condemned the      Netherlands' acceptance of euthanasia as a legal alternative to natural death. • An especially noteworthy section of this law recongnizes the validity of written requests orliving wills leaving the decision up to the physician if the patient becomes too debilitated to make his or her own judgment.  This is a giant step forward in the Death With Dignity movement, allowing for active euthanasia given strict safeguards.  As it is now a person considering hastening death must consider completely the act before he or she is too incapacitated to accomplish it. • Other European nations are considering similar legislation, including Britain, France, Switzerland and Belgium.