Assisted Suicide Is Back on the Oregon Ballot

PORTLAND, Ore. — Oregon’s pioneering topsy-turvy debate over doctor-assisted suicide is now underway . . . again. When voters narrowly passed a referendum approving the practice in 1994, this frontier-spirited state of 3.2 million became the first to sanction the controversial practice.

But opponents rallied, local courts blocked the proposed law and the Oregon Medical Assn. shed its neutrality and came out against the Death with Dignity measure, citing “flaws” highlighted by emerging medical research. Then, two weeks ago, the state Legislature put the same referendum on a special ballot this fall.

“A very, very strange situation,” said Jim Kronenberg, associate executive director of the medical association.

Adding to the intensity, the United States Supreme Court is expected to decide any day now whether terminally ill people have a constitutional right to get a doctor’s help committing suicide. If the justices leave that question up to the states--as legal analysts predict--Oregon will be a crucial testing ground in the nation’s escalating end-of-life battle.

“This is the abortion issue of the next century,” said Bill Taylor, a staff lawyer with the Oregon Legislature, by which he meant a highly emotional topic that divides along ideological and religious lines. Doctor-assisted suicide is “the issue of our time,” he said, “because abortion affects relatively few people--but everybody dies.”

Both sides in the Oregon dispute claim the same high moral ground of easing suffering. Indeed, a leading proponent of assisted suicide is an education and support group called Compassion in Dying, and a leading opponent is Physicians for Compassionate Care.

At least there is agreement that far too many people spend their final days in a cold institutional setting, often alone, enduring under-treated pain and subjected to futile medical heroics against their wishes.

The question of whether doctor-assisted suicide is the compassionate response to “prolonged dying,” as medical researchers call it, is expected to be the most expensive referendum in the state’s history. The warring campaigns spent about $2 million in 1994, and some analysts estimate that this year’s battle could cost $10 million--more than $5 per registered voter.

Opposing the practice are the Committee on the Right to Life and the Oregon Catholic Conference. Among those in favor are Oregon Right to Die, a political action committee, and the Hemlock Society, a suicide advocacy group.

Whatever their feelings about doctor-hastened death, many Oregonians are angry at the state Legislature for voting, 52-36, to put the 1994 measure back on the ballot. The Legislature has not sent an approved referendum back to the people since early this century, and the recent move is widely viewed as an attempt by conservative legislators to get the measure repealed.

Supporters of assisted suicide have vowed to exploit voter resentment of the lawmakers--thus hoping to make politics the issue, not medicine. “This is less about the right to die than the right to vote,” said the executive director of Compassion in Dying, Barbara Coombs Lee, a nurse and lawyer.

Derek Luow, 35, a cobbler who voted for the 1994 Death with Dignity measure, takes the lawmakers’ latest move as slap in the face. “I feel the Legislature has second-guessed the people’s decision,” he said. He still wants the right “to exit gracefully myself, if it comes to that.”

But his own shop, Shoes on the Run Instant Shoe Repair, is a microcosm of how divisive the issue is. Working alongside him was Mike Milne, a goateed 21-year-old, who has even less faith in doctors than legislators. He worries about what they would do if allowed to help patients kill themselves. “It’s not as if doctors even know who you are,” he said. “It’s a doctor’s job to keep you alive.”

Even Physicians Don’t Agree

Like prizefighters in their respective corners, the two leading physician adversaries sit at opposite ends of a hallway on the wooded hillside campus of Health Sciences University, the state’s only medical school.

At one end is the office of Dr. Peter Goodwin, 68, a scrappy South Africa native, proud liberal, lapsed Unitarian-Universalist and ethical relativist. He was chairman of the victorious 1994 Death with Dignity campaign.

At the other end of the hallway in the family medicine building is Dr. William Toffler, 48, a Roman Catholic so orthodox he no longer recommends or prescribes birth control devices to his patients. He is president of Physicians for Compassionate Care.

Faculty colleagues and friends for 17 years, they profess mutual admiration, but others note a growing strain on their relationship. Toffler was instrumental in recruiting Goodwin to the university from his private practice in Camas, Wash., but currently is not above heckling him in public.

“What I believe is that ethics is always debatable,” Goodwin was quoted by the Portland Oregonian as telling an audience recently.

“That’s a belief system!” Toffler interrupted from the other side of the dais.

Goodwin said in an interview that his advocacy of the right to doctor-assisted suicide is rooted in his experiences with suffering patients, including a man with inoperable bone cancer whose wife asked for help hastening his death. Goodwin said he refused and that the man “had a disastrous death,” which the now-retired family doctor declines to describe.

“To me this is a patient-driven issue,” he added. “I believe that physicians in general are not trained to listen and assess what’s going on in a [dying] patient’s mind and environment, so they make arbitrary decisions. Patients deserve more power.”

Goodwin acknowledges that legalizing assisted suicide may result in some abuses, just as some doctors now perform unnecessary surgeries. But he said checks and balances--such as professional guidelines and the threat of lawsuits--will regulate the practice. “Let’s see what happens when this truly is a realistic option for patients,” he said.

In its current form, the proposed law lets doctors hasten the death of only mentally competent people diagnosed as having six months or less to live. The patient must initiate the request and have no documented depression.

It also mandates a two-week wait between a patient’s verbal request and the signing of a long consent form, allows patients to change their minds and lets physicians who object to the practice opt out. All it allows a doctor to do is prescribe a lethal dose of drugs such as barbiturates, which patients then must swallow themselves. It prohibits euthanasia, in which a doctor would inject a lethal drug.

To Toffler, the practice violates the “sanctity of life” and the physician’s obligation to do no harm. “If doctors are doing that because patients are in pain--well, we have treatment for pain. If it’s because patients feel lonely and abandoned, we have treatment for that. If it’s because doctors are offering futile care to people who don’t want it, stop doing futile care.”

With pressure on hospitals and patients to lower health care costs, he said, the “right to die” will soon become the “duty to die.”

Coombs Lee and other advocates charge that Toffler unfairly influenced the recent Oregon debate by loading up the state medical association with anti-suicide forces recruited from his Physicians for Compassionate Care network. That scenario gets some support from the fact that the Oregon Medical Assn.’s nearly unanimous April vote against the Death with Dignity Act ran counter to a 1995 study showing that 60% of 2,700 physicians surveyed supported the concept. “The OMA changed its mind because the house of delegates was stacked,” she said.

Toffler does not deny the influence of his 1,060-member group. To the charge that he is trying to impose his religious beliefs on other Oregonians, he said he would be happy if he could be accused of being a good Christian.

The ‘How-To’ of Suicide

For all the rarefied discussion of ethics, much of the Oregon debate zeros in on the lowly details of killing oneself.

One issue is the effectiveness of oral medication as a suicide tool. At public forums, medical association meetings and legislative hearings this spring, Toffler and the anti-suicide lobby have argued that suicide by barbiturate overdose can be an ordeal. They have cited research in the Netherlands, where doctor-assisted suicide and euthanasia are not criminal under certain circumstances. Studies there have suggested that a significant number of people vomit the pills before they take full effect. That can result in a lingering death or an “incomplete suicide,” as some researchers call it.

Goodwin and other suicide-rights proponents retort that legalizing the practice should reduce the risk of botched outcomes. At the moment, he said, physicians are helping people kill themselves, but because the practice is illegal they have to be coy about it--not specifying how many sleeping pills to take. But if the practice were out in the open, a doctor could prescribe not only suitable barbiturates but also an anti-nausea drug to keep them down.

As it is now, said Compassion in Dying’s Coombs Lee, patients who want a hastened death “have no guidance. They have probably had to scrounge and hoard whatever pills they could find. The horror stories are what happen now.”

There are other down-to-earth issues. Virginia Tilden, associate dean of research at the Health Sciences University’s nursing school, is studying how family members might be affected by consenting to or simply being aware of a loved one’s assisted suicide. She also worries that a lethal dose of oral medication kept around the house in anticipation of a suicide could be dangerous to others.

“It puts a little more risk of a toddler’s accidental poisoning or perhaps a depressed teenager’s suicide,” she said. “It’s rather like having a gun in the home.”

The university’s center for medical ethics takes no official position on assisted suicide, but it has been busy highlighting the Death with Dignity Act’s shortcomings. For instance, the measure is supposed to cover only Oregon “residents,” but doesn’t define that term, raising the possibility that out-of-staters might pour into Oregon seeking help in dying.

As Oregonians embark on another gorgeous green summer, they are also bracing for a grim season of public debate about all sorts of deathbed scenarios. Perhaps surprisingly, though, the great emphasis on death and dying the last few years has been a boon to Oregonians’ well-being, according to the head of the medical ethics center, Dr. Susan Tolle. She calls it a “wake-up call” to health professionals to improve end-of-life care.

There has already been measurable progress, including more people dying at home with “comfort care” rather than in a hospital. Meanwhile, patients who do remain in the hospital are more likely to have their pain aggressively treated.

“So far, it has had a good effect in Oregon, though it has not had a single day it was legal,” she said of the 1994 “yes” vote. “I can’t say what would happen if [doctor-assisted suicide] were put into practice. Would it keep us in the hot seat and keep making things better? Or would it become the easy way out? I don’t know.”