The most vulnerable patients may be subject to abuse.
Editor’s note: This is the second installment of a two-part series exploring the issues of assisted suicide in America. See part one here.
Barbara Wagner, a lifelong smoker, quit after her diagnosis of lung cancer in 2005, according to news accounts. The Oregon Health Plan paid for chemotherapy, radiation, a special bed, and a wheelchair, and the cancer went into remission. When it returned in 2008, Wagner’s oncologist prescribed a drug to slow its growth. The drug might have given her another four to six months to live, but the Health Plan ruled it as “futile care,” defined as any treatment without at least a 5 percent survival rate after five years. Instead, she was offered either comfort care — or a prescription for a fatal dose. After a flurry of press coverage, Wagner received the drug free from the manufacturer, but died soon after.
Is assisted suicide in effect a cost-saving measure? As Marilyn Golden, a senior policy analyst with the Disability Rights Education and Defense Fund, and Diane Coleman, president and CEO of Not Dead Yet, a disability-rights group, point out, a fatal dose of pills costs much less than drugs to prolong life or other kinds of end-of-life care.
Another concern is that the laws may not adequately protect people suffering from mental illness. N. Gregory Hamilton, an Oregon psychiatrist and co-founder of Physicians for Compassionate Care, has testified that — although psychiatric evaluation is required for patients suspected of harboring a mental health condition — patients with dementia or a history of depression have killed themselves under Oregon’s law. (See “Why Some Make the Case for Assisted Suicide” for more information about the Oregon law).
Terminally ill people who choose suicide report on Oregon state questionnaires that they are concerned about maintaining their autonomy and dignity. Newly disabled patients may have similar concerns. As Golden observes, newly disabled people often feel humiliated when they receive hands-on care. “Disability groups, however, disagree that needing help in dressing, bathing, and other intimate daily tasks robs a person of dignity. Unfortunately, popular culture has done virtually nothing to educate the public about how people with severe disabilities actually live autonomous and dignified lives. Our lives are portrayed as tragedies or sensationalized as heroism, but the real-life issues and coping styles that most people will need if they live long enough are left out of the picture,” she writes.
The newly-disabled often fall into despair. In his autobiography, “Still Me,” Christopher Reeve describes asking his wife to help him commit suicide after he was paralyzed in a riding accident. She said, “I understand how you feel, but you’re still you and I love you,” giving him the title of his book. Reeve explains that he was testing her to see if she was willing to take over his care.
What if the prognosis wrong? In one study of 365 physicians and 504 hospice outpatients, death occurred a month or more after the predicted date for 12.6 percent of the patients, a total of 59. “The disability community is full of people who have long outlived their prognosis,” says Golden. “If insurance denies or even delays life-sustaining treatment, the insured is steered toward suicide. Proponents say financial pressures don’t play a role, but there’s no investigation. No abuse hotline. Doctors are required to report, but there’s no investigation and no penalty if they don’t. Oregon confirms that they can’t confirm compliance with the law. The state doesn’t have the authority to investigate.”
The protections under Oregon’s law are easily overcome, argue psychiatrist Herbert Hendin and neurologist Kathleen Foley in a 2008 article in the Michigan Law Review. “The evidence strongly suggests that these safeguards are circumvented in ways that are harmful to patients,” they write. They cite the case of a woman who received a fatal prescription from a third doctor after two doctors had turned her down — why doesn’t the law require a method for adjudicating such disagreements? In another case, a psychological evaluation turned out to be a true-false questionnaire her children read to her at home; the psychologist never saw her.
Although we tend to think of family members as trustworthy, Golden and others note the growing problem of elder abuse. One comprehensive survey found that 7.6 percent of elders reported some kind of abuse, often involving finances. The federal National Center on Elder Abuse reports evidence that only a small percentage of cases are ever reported to authorities. Most of the abusers are members of the family. As Golden points out, assisted-suicide laws can play into their hands: heirs can pick up a lethal prescription or hand the drug to a person under their care.
Palliative care — keeping the patient out of pain — is a legal option everywhere; why compound the risk of abuse, critics of assisted suicide say?
March 04, 2015
Christopher Nystuen, MD, MBA