Oregon Law Fuels Debate on Suicide

On a Sunday morning in late January, with cancer consuming his lungs and bones, 42-year-old David Prueitt swallowed a cupful of applesauce mixed with the bitter powder of 100 barbiturate pills.

In six minutes, the once-rugged logger fell asleep. His wife, Lynda, watched his chest rise and fall and waited for him to die.

Prueitt expected to become one of more than 200 critically ill Oregonians who have taken the end of life into their own hands under the state’s assisted suicide law, which took effect in 1998.

But Prueitt didn’t die. He slept for three days. Then he woke up.

“What happened?” he asked his wife, who still supports the Oregon law. “Why am I not dead?”

Later, Lynda Prueitt says, he told her that he had been in the presence of God while unconscious. “God told him, ‘This is not the way to get into heaven,’ ” she said.

Prueitt, the only person to have survived a full dose of the barbiturates prescribed under the law, succumbed to his cancer two weeks later, but his story has lived on, fueling debate over not just the Oregon law but also a similar statute under consideration in California.

Sacramento lawmakers are weighing a bill that would essentially copy Oregon’s Death With Dignity Act, the only assisted-suicide law in the nation. The bill, which would free doctors from liability in prescribing lethal doses of drugs to terminally ill people, has cleared one Assembly committee. It faces a vote Wednesday in the Assembly Appropriations Committee. Its authors expect it to pass that hurdle but anticipate a close vote on the Assembly floor in the next week. AB 654 by Democratic Assembly members Patty Berg of Eureka and Lloyd Levine of Van Nuys would, as the law does in Oregon, allow those with incurable diseases to get a lethal prescription after asking for it once in writing and twice orally, then waiting two weeks. And as in Oregon, the California legislation would require that they ingest the drugs themselves.

Californians have just begun the debate over whether government should sanction physician-assisted suicide, but Oregon has seven years of experience. In a sense, it is the nation’s laboratory, so it is no surprise that Californians on both sides of the issue are looking to Oregon’s example for evidence to support their cases.

There, the worst-case scenarios cited by opponents -- that people would move to Oregon from all over the country to die, that inheritance-hungry children would coerce elderly parents to take the lethal drugs -- have not come to pass.

But the law has continued to raise thorny issues, such as those in Prueitt’s case, which is being investigated by the state Board of Pharmacy.

Between 16 and 42 people have ended their lives each year through legally sanctioned suicide since the law’s passage, according to annual reports by the Oregon Department of Human Services. Eight to 26 others each year have gotten the prescriptions but not used them.

Those who have opted to end their lives with physician assistance are almost evenly split between men and women, with a median age of 69. They are as likely to be Republicans as Democrats. Most have cancer, Lou Gehrig’s disease or chronic respiratory illness. They tend to be better educated and are more likely to be divorced or never married than other Oregonians dying of the same diseases. Residents of the more rural eastern part of Oregon were less than half as likely to use physician-assisted suicide as those in the more urban west, according to state reports.

Doctors of those who request help hastening their deaths say that the most frequently mentioned end-of-life concerns are a decreasing ability to do the things that make life enjoyable, loss of autonomy and loss of dignity.

One issue raised by opponents when the Oregon law was first debated was whether the drugs would consistently work without causing other side effects, like vomiting. Proponents dismissed those concerns. But between 1998 and 2004, 10 people have regurgitated the drugs. Most still died fairly quickly -- half of those who took the medication died within 30 minutes -- but one person who regurgitated the drugs last year lingered for 31 hours.

Prueitt’s case was the most exceptional. Still, his story has become a rallying cry for opponents of physician-assisted suicide.

Assemblyman Dennis Mountjoy (R-Monrovia), who opposes the California bill, urges Californians in a commentary posted on his website to “take a look at Oregon.” He goes on to cite Prueitt’s case as an example that “not all Oregon’s assisted suicides are so simple.”

And Physicians for Compassionate Care, a group of doctors and other health professionals opposed to assisted suicide, issued a press release saying that Prueitt “proved the reality that dying by overdose is not easy, comfortable and certainly not dignified.”

Lynda Prueitt, who reluctantly agreed to help her husband get the lethal prescription, tells his story because he asked her to do so in order to warn others.

But speaking her own mind, she reflects the majority of Oregonians, who defend the assisted suicide law.

“That option should be there,” Prueitt said. “Leave it up to the people. Whatever happens between them and God, that is between them and God.”

The law enjoys such widespread support in Oregon that politicians challenge it at their peril. “Opposing the law in Oregon is a political liability now,” said Barbara Coombs Lee, co-executive officer of Compassion & Choices, a nonprofit group with offices in Portland and Denver that is sponsoring the California legislation.

Even the most ardent opponents acknowledge that their best chance of overturning the law comes not from Oregon citizens but from the Bush administration, which in 2001 interpreted the federal Controlled Substances Act to ban lethal barbiturate prescriptions.

Federal courts have so far ruled against the Bush administration and upheld Oregon’s law. Last November, then-Atty. Gen. John Ashcroft appealed to the U.S. Supreme Court, which agreed to hear the appeal in its next term, beginning in October.

Oregon voters first passed the Death With Dignity Act as an initiative in 1994 by a 51%-49% margin. The National Right to Life Committee immediately went to court to block it and succeeded in delaying the law’s implementation. In October 1997, the U.S. Supreme Court rejected that challenge, saying states have the right to set their own courses on assisted suicide.

The Oregon Legislature, divided over the law, put its repeal on the November 1997 ballot. More debate only led to greater support. Oregon voters rejected repeal by 60%. Many voters expressed annoyance with the Legislature for making them vote again.

Though Vermont, Washington and Hawaii have considered legislation to indemnify doctors who write lethal prescriptions for the dying, no other state has followed Oregon. California weighed the issue in 1992, with an unsuccessful initiative that would have legalized euthanasia by allowing doctors to give fatal injections.

Experts can’t say exactly why Oregon, with a tenth of the population of California, forged this path. But they note that Oregon has long stood out on end-of-life care, with high rates of morphine use for the dying and a greater percentage of its residents than the national average getting hospice care and dying at home instead of hospitals or nursing homes. Oregonians are also less connected to established churches than the rest of America. Academic surveys have found Oregonians answered “no religion” most frequently to a question about religious identity.

“There is this crusty sense of independence that’s part of the ethos here,” said Linda Ganzini, a professor of psychiatry and medicine at Oregon Health & Science University who has studied the Death With Dignity Act extensively.

The original campaign to pass the law was heated, with the opposition financed heavily by the Catholic Church. Television and radio ads warned that if the law passed, people would die in large numbers of horrible deaths or that doctors and pharmacists would refuse to participate.

Former Gov. Barbara Roberts, who supported the law, called the ads in 1997 less “ugly” than those of 1994.

“Death came out of the closet,” she said. “People were used to talking about it and there was a comfort level people had in ’97 that was not there in ’94.”

In California, the debate over the doctor-assisted suicide bill has also covered morality and mechanics. But Oregonians have flown south to testify at each of the three legislative hearings on AB 654. California’s debate has become a forum on Oregon’s experience.

Kenneth R. Stevens Jr. is one of the law’s most outspoken critics. A 65-year-old Portland radiation oncologist who has studied assisted suicide laws around the world, Stevens says so few people use the Oregon law that it isn’t needed.

The law violates the role of physicians and undermines the relationship between doctors and patients, he argues. It opens the door to euthanasia and shifts a harmful emotional burden to doctors. With Oregon trimming what it spends on medical care for the poor and elderly, Stevens said, “the concern we have is that this could become someone’s only choice.”

Noting that many of the people who choose suicide have been described by their doctors as strong-willed and fearful of losing autonomy, Stevens calls it death with vanity, not dignity.

“These are prideful, controlling people,” Stevens said.

His apprehension about assisted suicide extends to 1982 when his wife, the mother of six children, was dying of malignant lymphoma that had spread to her brain, spinal cord and bones. They visited her doctor, and it was clear nothing more could be done.

“As we were about to leave, he said, ‘Well, I could write a prescription for an extra large amount of pain medicine,’ ” Stevens said. “It was very subtly said, and we understood the intended message. As I helped my wife to the car, she said, ‘Ken, he wants me to kill myself.’ It just devastated her.”

His wife died six days later without the prescription.

“I’ve come to the conclusion when a doctor does this,” he said, “it’s doctor-ordered death.”

Stevens is not just philosophically opposed to the Oregon law. He is troubled by how it has been implemented and argues that it is carried out in secrecy. The law requires doctors to report to the state when they write a lethal prescription, but there are no teeth to enforce their doing so.

Stevens also worries that the people who are present at assisted suicides tend to be supporters, with a built-in motive not to report problems. He notes that in more than 70% of assisted suicide deaths, a volunteer from the nonprofit organization Compassion in Dying is present. The prescribing doctor is present in only 30% of the cases.

“We’re supposed to trust them to tell us there are complications?” Stevens said. “There’s no oversight for it.”

Ganzini, the Portland researcher, has surveyed Oregon’s doctors and found that roughly a third are not willing to write the lethal prescriptions.

Nick Gideonse, a family doctor who directs a southeastern Portland neighborhood clinic for Oregon Health & Science University, understands why. With the Bush administration attempting to overturn the law, doctors risk their licenses. And they risk offending other patients who might consider a lethal prescription a betrayal.

Gideonse considers it a privilege. He has written the lethal prescription six times. He has watched three patients take the drugs and die.

“I’ve heard some of the opponents say that physicians are taking on God or that it’s somehow intoxication of power to provide this,” said Gideonse, 44. “No, it’s a role of tremendous service. The relief from the patients and family is palpable.”

“You can go through a lot of medical care with illusions of curative options or opting not to discuss the elephant in the room,” Gideonse said. “In the process of doing this, you discuss the closest family relationships, the depth of feeling and history between parents and children. You discuss core issues of the value of life. You discuss core issues of the fear of and awfulness of not just death, but these terrible diseases.”

Without a safe, legal way to discuss hastening death, Gideonse said, patients and doctors struggle in awkward, oblique conversations. Patients may end up hoarding pills for a much less certain suicide, starve themselves or kill themselves by a violent method.

When he was a medical resident in Portland during the debate over the law in the 1990s, his professors were split on the issue. Gideonse opposed it for fear it would be abused. He was convinced otherwise by a fellow doctor dying of cancer.

The friend told him that at times his treatment was so miserable that if that was all he faced for the rest of his life, “at least knowing he had the option of final control would be tremendously important,” Gideonse said.

Pat Greene, a 48-year-old landscape designer in Eugene, paid close attention to the 1994 ballot campaign and recalls spirited debate. She voted for the law. She never expected to use it until she heard the word “malignant” in June 2003.

Doctors told her then that the cancerous tumors wrapped around her bronchial tubes meant she had only 18 months to live. Last year, they found cancer in her liver and lymph nodes. A few months ago, they spotted three tumors in her brain.

Greene is witty and lively, with a Virginia lilt. She sits cross-legged on the couch in her small mustard-colored house with purple tulips and dogwood blooming in the front yard. Occasionally, she shifts her brown wig to scratch her head.

She now has a diagnosis of six months or less to live, the first of several requirements for getting a lethal prescription. But recently, as she endured her fourth round of chemotherapy, the news was filled with the pope’s death and debate over whether Terri Schiavo, who had slipped into a persistent vegetative state 15 years ago, should be kept alive artificially. As she watched television in the middle of the night, Greene said, she decided to get a lethal prescription, even though she still hopes not to need it.

“Nobody can take it away from me,” she said. “It’s my right and my responsibility. Otherwise somebody else has to sit around and think about whether to pull the plug.” On April 20, Greene paid $1,150 for what she calls her “pass”: Four squat bottles of clear liquid Nebutol. She didn’t pick them up at the local pharmacy, where they know her well.

“It would break their heart,” said Greene, “and I don’t want to break their heart.”

The pharmacist asked her whether she would like cherry flavor. She declined when she learned the flavoring would make the drugs expire more quickly.

“I said, nope, give me the one with the longest shelf life,” said Greene, “and I’ll renew it in 2007.”

Meanwhile, she plans to visit family in the South this summer and tour Ireland in September. But she’s realistic; getting the Nebutol was on her to-do list, along with marking her possessions for distribution after her death and arranging to donate her body to science.

“I still have a great quality of life,” Greene said. “And I actually anticipate having a great quality of life until I die. I base that on ... how much I can give back and how much love there is in my life.”

But the cancer, which she calls “just a bad one,” could get into her spine and create paralysis. She does not want to die in a coma as her father did in 1994, back in her Appalachian hometown of Wise, Va. He died of Lou Gehrig’s disease, or amyotrophic lateral sclerosis, which destroys the nerves that control muscles.

“I have been told by some of my spiritual guides,” said Greene, “that I’ll know when it’s time.... And I don’t know yet. And I’m not at all ready to let go.”

The decision to get the prescription, she said, “was easy for me to make.”

“I can’t imagine anyone else not wanting that decision for themselves.”

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(BEGIN TEXT OF INFOBOX)

Death by prescription

Oregon voters passed the Death With Dignity Act in 1994. In effect since 1998, it allows terminally ill people to get a doctor’s prescription to end their lives.

Provisions of the Oregon law

A person seeking a prescription must be:

* An Oregon resident

* At least 18 years old

* Capable (able to make and communicate decisions)

* Diagnosed with no more than six months to live

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To get the prescription, a person must give a doctor:

* A written request signed by two witnesses

* Two oral requests separated by 15 days

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Before a prescription is issued, two physicians must:

* Confirm the diagnosis

* Determine that the person is capable

* Inform the person of alternatives, including pain control

* Ask, but not require, that the person tell family members

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Terminally ill people must take the drugs themselves and doctors must notify the state.

Source: Oregon Department of Human Services. Graphics reporting by Nancy Vogel