Vermont House Human Services Committee
Representative Ann Pugh, Chair
Hearing on H-168
Proposal to legalize physician-assisted suicide in Vermont
April 14, 2005, Testimony by Telephone
Testimony of Kenneth R. Stevens, Jr., M.D.
Physicians for Compassionate Care Education Foundation
Professor and Chair, Department of Radiation Oncology
Oregon Health & Science University, Portland, Oregon
I have been in the practice of Radiation Oncology, treating cancer
patients, for 38 years in Oregon. I have been Professor and Chair
of the Department of Radiation Oncology at Oregon Health & Science
University for 16 years.
I have studied Oregon's assisted-suicide law since its passage in
1994. The more I have learned, the more I realize the significant
harm and danger of assisted suicide to the vulnerably ill and to
ASSISTED SUICIDE IS DOCTOR-DIRECTED SUICIDE
Physician-assisted suicide represents a reversal of the proper role
of physician as "healer, comforter, consoler", to an improper role
of helping patients commit suicide. Physician-assisted suicide is
really doctor-directed suicide, because the prescription is a written
directive or order to the patient.
The false message of assisted suicide proponents is that doctors
can do a better job of killing patients than they can of caring for
their medical needs.
MY WIFE'S EXPERIENCE
I have personal experience regarding this matter. My wife had been
suffering for three years from advancing malignant lymphoma. In May
1982, we met again with her physician to see what more could be done
for her. It was evident that not much more could be done other than
comfort care. As we were about to leave his office, her physician
said, "Well, I could write a prescription for an 'extra large' amount
of pain medication for you." He did not say it was for her to hasten
her death, but she and I both felt his intended message. We declined
the prescription, since her current pain medication was sufficient.
As I helped her to our car, she said, "He wants me to kill myself!" She
and I were devastated. How could her physician, her trusted physician,
subtly suggest to her that she take her own life? We had felt much
discouragement during the prior three years, but not the deep despair
that we felt at that time when her physician subtly suggested that
her suicide be considered. Six days later she died naturally, with
dignity and at ease in her bed, without the suggested medication.
Assisted suicide destroys the trust between patient and doctor.
PAIN IS NOT THE ISSUE
There is not one instance in Oregon of assisted suicide being used
for actual untreatable pain. Assisted suicide is being used for psychological
and social concerns.
AUTONOMY AND CONTROLLING PEOPLE
The great majority of those dying of assisted suicide in Oregon
have been upper-middle class Caucasians. Oregon assisted-suicide
patients have been described by their doctors as being fiercely independent
and controlling. Society should always fear laws that are established
by and for controlling people. History has taught us that once such
laws are established, the poor and vulnerable are discriminated against.
It is not surprising that the black community is much less likely
to favor assisted suicide compared to the white community. Families
of Oregonians dying between June 2000 and March 2002 were interviewed
regarding assisted suicide. Whereas 18% of the dying whites personally
considered assisted suicide (none of these people used assisted suicide),
there was not one of 62 blacks that considered it.1 There have been
no black deaths among the 208 deaths in Oregon between 1998 and 2004.3
THE PROBLEMS WITH "SAFEGUARDS"
Assisted suicide proponents talk about the "safeguards" with Oregon's
assisted suicide law. The fact that the word "safeguards" is used,
is an indication that assisted suicide is dangerous and unsafe for
the general public. The so-called "safeguards" are really boundaries
or restrictions around assisted suicide. They may be considered as
a means of protection against abuse, but they also act as a barrier
or restriction to those who find themselves outside those boundaries.
AUTONOMY AND SAFEGUARDS DON'T MIX
When persons desiring assisted suicide finds themselves outside
the boundaries that are written in the law's "safeguards", they want
to bypass or stretch the boundaries. This is especially true of people
who have been described by their doctors as being extreme in their
desire for control of their lives and death.
The so-called "safeguards" or boundaries in the Oregon law are:
- Diagnosis of a terminal illness; less than 6 months to live.
- Mentally capable.
- >18 years of age.
- Lethal drugs self-administered and taken by mouth.
- Lethal injection not permitted.
OREGON'S ASSISTED SUICIDE "SAFEGUARDS" ARE NOT BEING FOLLOWED
With virtually every case that has come to public light, the closer
one looks at individual cases, the uglier is the reality.
The assisted suicide law provides no protection for the depressed
or mentally ill. Shockingly, only 5% of those dying from assisted
suicide in 2003 and 2004 had a mental health consultation.2, 3
In Oregon, patients with mental disorders can receive lethal drugs
to kill themselves. Nationally, the majority of forensic psychiatrists
believe that the presence of major depressive disorder should result
in an automatic finding of incompetence.4
Kate Cheney was a woman in her 80s with cancer who requested assisted
suicide. After a psychiatric evaluation determined that she had dementia
and was not mentally capable, she and her family sought a psychologist's
evaluation that felt that she was capable. This is an example of "doctor-shopping" to
get a desired opinion. She finally received the prescription for
lethal drugs from a Kaiser HMO doctor.5
Michael Freeland was a 62-year old man newly diagnosed with lung
cancer, and with a history of depression and prior suicide attempt.
He received lethal drugs from an assisted suicide doctor without
a mental health consultation. He was later admitted to a psychiatric
ward. When he was discharged from the psychiatric ward, the doctors
and court judged him incompetent. Yet this man had a bottle of lethal
drugs in his house.6 Was this safe? Where were the safeguards?
Jake Harris was a man with multiple tumors in his brain, whose thinking
was slipping and parts of his brain were blinking off. And in that
condition he received the lethal medication.7
Patrick Matheny8 and Barbara Houck9 were patients with ALS (Amyotropic
Lateral Sclerosis), who had problems swallowing and being able to
self-administer the medication. Mr. Matheny had to be "helped" by
his brother-in-law because of his trouble swallowing. Mrs. Houck
had the lethal medication spoon-fed into her mouth. Where was the
self-administration in these cases?
Determining that a person has less than six months to live (terminal)
is fraught with error. Some Oregonians who have received the prescriptions
for lethal medication have lived far longer than 6 months, some for
more than 2 years.
The "slippery slope to euthanasia" has occurred in Oregon. In 1996,
a doctor in Corvallis, Oregon had a patient die from lethal injection
(euthanasia). He was not criminally prosecuted and his medical license
was suspended for only two months.10 The county district attorney
did not prosecute the case because he felt the political climate
of having legal assisted suicide in Oregon would prevent a conviction
Many doctors are writing prescriptions for lethal drugs to patients
for whom they have not previously cared. Dr. Peter Rasmussen reported
that "75% of the patients who come to him regarding assisted suicide
are people he has never seen before". Regarding the "slippery slope" of
assisted suicide, Dr. Rasmussen said, "I think all involved in
the Oregon law must recognize that we are on a slippery slope, and
we have to be careful with every step. But just because it's a slippery
slope doesn't mean we shouldn't go there." 11
THERE ARE FAILED ASSISTED SUICIDES IN OREGON
"Why am I not dead?" read the headline of the March 4, 2005, The
Oregonian newspaper.12 "An Estacada [Oregon] man's attempt at doctor-assisted
suicide took a bizarre turn when he [David Pruiett] woke from a coma
nearly three days later and lived for two more weeks."
This was not the first case of a failed assisted suicide attempt.
In 1999, a man had problems after taking the pills, his wife called
911, he went to a hospital, and later died in a nursing facility
of natural causes.13 Yet this failed physician-assisted suicide was
not reported in the 2000 year report from the Oregon state agency.
THERE ARE OTHER COMPLICATIONS IN OREGON
In 2003, a patient drank only one-half of the lethal medication,
and then vomited one-third of what he had taken, and he lived 48
hours before finally dying.2 What was the true cause of death, since
he had taken a less-than-lethal-dose of short-acting barbiturate?
In 2004, at least 3 patients vomited , and 4 patients lived from
7 ½ to 31 hours after taking the drugs.3 This is not surprising
since Dutch doctors have cautioned that death with assisted suicide
is not always easy or peaceful, with complications occurring up to
20% of the time.
THERE IS SECRECY REGARDING WHAT IS HAPPENING IN OREGON
There is lack of proper oversight of Oregon's assisted suicide by
the Oregon Department of Human Services. A March 8, 2005, Oregonian
newspaper editorial, in referring to the relative lack of reported
complications in Oregon's assisted suicide law, stated: "But how
can we be for sure? As the Pruiett case shows, the people reporting
the central facts of the [Oregon] experiment are not disinterested.
The results must be considered suspect because they may be shaded
by people who, for various reasons, want things to seem fine.. The
facts must be allowed to emerge through objective assessment. This
case demonstrates that Oregon's mechanism for that simply doesn't
According to the Compassion in Dying organization, about three-fourths
of those dying from assisted suicide in Oregon are doing it under
the direction of that organization. That organization has a vested
interest in not reporting complications or problems.
THERE IS NO REAL MONITORING OF OREGON'S ASSISTED SUICIDES
When Mr. Pruiett's failed assisted suicide was made public, the
Oregon Department of Human Services (DHS) publicly stated that they
had "not authority to investigate individual Death with Dignity cases.
The state law authorizing physician-assisted suicide neither requires
or authorizes investigations by DHS." 15
We are dependent on self-reporting by doctors, and in over 70% of
assisted-suicide deaths in 2003 & 2004, the prescribing doctors
were not there when the patients took their lethal medications, so
how do they know what happened at the time of death?2, 3 They don't.
This information is obtained second or even third hand. The Oregon
State Dept. of Human Services has commented that what they receive
from doctors might be a "cock and bull story".16 We really do not
know what is going on in Oregon.
INJECTABLE PENTOBARBITAL IS BEING USED FOR MOST ASSISTED SUICIDES
In 2003 and 2004, 78% (62/79) of the Oregon assisted suicide deaths
were from pentobarbital. Pentobarbital is currently only available
in a liquid formulation. It is officially named "pentobarbital sodium
injection, USP; Nembutal sodium solution". Its only indication and
usage is as an intra-muscular or intra-venous injection. It is not
designed for FDA authorized for oral ingestion. Now that this form
of lethal barbiturate is being used for assisted suicide, there is
nothing to prevent its use by lethal injection, which is illegal
FINANCIAL AND SOCIETAL DANGERS,
ASSISTED SUICIDE MAY BECOME THE ONLY CHOICE FOR SOME PATIENTS
In Oregon, for a patient with cancer with a less than 5% chance
of living 5 years, Medicaid (Oregon Health Plan) will only pay for "Comfort
Care", which includes assisted suicide. Based on the Prioritized
List of Medical Services, Oregon Medicaid will not pay for curative
medical or surgical cancer treatment services for patients with a
less than 5% chance of living 5 years.
In 2003, Oregon Medicaid stopped paying for medicines for 10,000
Oregonians who had been on Medicaid (Oregon Health Plan). This included
patients with AIDS, bone marrow transplants, mentally ill and those
A physician member of Physicians for Compassionate Care received
a phone call in the spring of 2003, from a man requesting assisted
suicide. The man said, "The state of Oregon Medicaid has stopped
paying for the pain meds I take for my chronic back pain. If they
won't pay for my pain meds, they might as well pay for my suicide."
In December 2004, the Oregonian newspaper reported that 50.000 Oregonians
had been cut from the Oregon Health Plan, and that the state plans
to cut another 25,000 Oregonians from the plan by June 2005, to keep
the state budget balanced.17
These cutbacks in medical-care financial support are killing Oregonians.
It was reported in The Oregonian newspaper in December 2002 that
there had been 94 mental health-related deaths because of the state
cutback in mental health services.18
The vulnerable poor of Oregon have very limited access to health
care. Sixty percent of Oregon doctors limit or do not see Medicaid
patients. More than 40% of Oregon physicians limit or do not see
With all of these problems with reduction in health care to the
vulnerably poor in Oregon, the Oregon Health Plan (Medicaid) continues
to pay for physician-assisted suicide. We are concerned that assisted
suicide may become the "only choice" for some vulnerable and ill
END-OF-LIFE CARE IS MIXED IN OREGON
Assisted suicide proponents erroneously claim that the legalization
of assisted suicide has made Oregon a leader in the care of dying
patients and in the use of pain medication. The facts do not support
Oregon ranked high in per capita use of morphine before assisted
suicide became legal. Many other states have enacted or strengthened
laws to ban assisted suicide, and per capita use of morphine in those
states has increased in every case.20
A national organization, "Last Acts", issued a "report card" in
November 2002 to states regarding their end-of-life care. Oregon
was given a "D" grade for hospice (less than 1/3rd of dying Oregonians
used hospice), and an "E" grade for palliative care programs.21
Regarding assisted suicide patients who want nothing to do with
hospice care, Ann Jackson, Executive Director of the Oregon Hospice
Association, in a 2003 Oregonian newspaper interview, said, "In effect,
they've said no to hospice, either because they don't believe we
in hospice can meet their needs, or we're not meeting their needs."22
After four years of assisted suicide in Oregon, there were almost
twice as many dying patients in moderate or severe pain or distress,
as there had been prior to Oregon's assisted suicide law being used.23
Those who erroneously blame the increase in pain and distress on
the DEA directive of Nov. 6, 2001, fail to realize that only one-fourth
of the June 2000 to March 2002 time period occurred following the
date of that directive.
COMPARISON OF ASSISTED SUICIDE RATES BETWEEN STATES
There has been a false claim that Oregon has a lower assisted suicide
rate than that of other states.24 There is no truth to that report.
Dr. William Toffler and I have recently written an article that shows
that we do not know what the assisted suicide rate is in states other
than Oregon.25 There is no evidence that legalization of assisted
suicide in Oregon has decreased the rate of physician-assisted suicide.
Oregon continues to have a high suicide rate among the elderly.
Oregon has a suicide rate (excluding assisted suicide) of the elderly
(65 and older) that is one and a half times the national average.26
I hope you will learn from the problems with physician-assisted
suicide in Oregon. Assisted suicide is not needed, and it puts vulnerable
people at risk. The citizens of Vermont need to concentrate on improving
end-of-life care and palliative-care programs, and not on promoting
unnatural assisted suicide.
1 Tolle SW, Tilden VP, Drach LL, Fromme EK, Perrin NA, Hedberg K.
Characteristics and proportion of dying Oregonians who personally
consider physician-assisted suicide. J Clin Ethics 2004;15:111-118.
2 Sixth Annual Report on Oregon's Death with Dignity Act, Oregon
Department of Human Services, March 10, 2004, www.ohd.state.or.us/chs/pass/ar-index.cfm.
3 Seventh Annual Report on Oregon's Death with Dignity Act, Oregon
Department of Human Services, March 10, 2005, www.ohd.state.or.us/chs/pas/ar-index.cfm.
4 Ganzini L, Leong GB, Fenn DS, Silva JA, Weinstock. Evaluation of
competence to consent to assisted suicide: Views of forensic psychiatrists.
Am J Psychiatry. 2000; 157:595-600.
5 Barnett EH. Is Mom capable of choosing to die? The Oregonian. October
6 Hamilton NG, Hamilton C. Competing paradigms of responding to assisted
suicide requests in Oregon: Case report. American Psychiatric Association
Annual Meeting Symposium on Ethics and End-of-Life Care: New Insights
and Challenges, New York City, May 6, 2004. To be published in Am
J Psychiatry, April, 2005. (available at www.pccef.org, May 6, 2004)
7 Klare S. Jake Harris, in Compassion in Dying, edited by BC Lee
(Troutdale, Oregon, NewSage Press), 2003, p 102.
8 Barnett EH. Man with ALS makes up his mind to die. The Oregonian,
March 11, 1999.
9 Frey J. A death in Oregon: One doctor's story. Washington Post,
November 3, 1999.
10 American Medical News. Board sanctions physician for 'active euthanasia'.
August 11, 1997.
11 Robeznieks A. Oregon sees fewer numbers of physician-assisted
suicides. American Medical News April 4, 2005.
12 Don Colburn, Why am I not dead?, The Oregonian, March 4, 2005.
13 Hamilton C. What's hiding behind the numbers?. Brainstorm March
2000, pp 36-38.
14 Editorial. Living with the dying 'experiment'. The Oregonian.
March 8, 2005.
15 No authority to investigate Death with Dignity case, DHS says.
Oregon DHS News Release March 4, 2005.
16 CD Summary, A year of dignified death, Oregon Health Division,
March 16, 1999, Vol 48, No. 6.
17 Beggs CE. Governor proposes small school aid boost, new lottery
games. The Oregonian. The Associated Press. December 1, 2004.
18 Roberts M. Did they have to die? The Oregonian. December 29, 2002.
19 Survey shows patient access problem grows. The Scribe. Published
by the Medical Society of Metropolitan Portland. November 19, 2004.
20 Americans for Integrity in Palliative Care: Written testimony
presented to the American Medical Association Annual Meeting, June
21 Last Acts, Press Release, November 18, 2002.
22 Colburn D. Suicide: Study is based on interviews. The Oregonian.
June 12, 2003.
23 Fromme EK, Tilden VP, Drach LL, Tolle, SW. Increased family reports
of pain or distress in dying Oregonians: 1996 to 2002. J Palliative
24 Ganzini L, Dobscha SK. Clarifying distinctions between contemplating
and completing physician-assisted suicide. J Clinical Ethics 2004;15:119-122.
25 Stevens KR, Toffler WL. Comment on Ganzini and Dobscha regarding
comparing rates of physician-assisted suicide in Oregon with that
of other states. J Clinical Ethics 2004;15:363-364.
26 CD Summary, Elder Suicide in Oregon, Epidemiology Publication
of the Oregon Department of Human Services, February 22, 2005, Vol.
54, No. 4.