The Oregon Report Don't Ask, Don't Tell

Abstract

In a public document,[1] an article in the New England Journal of Medicine,[2] a National Press Club briefing, and visits to various congressional offices, the Oregon Health Division (OHD) has argued that assisted suicide is being carried out safely under the state's Death with Dignity Act. Unfortunately, the report is marked by its failure to address the limits of the information it has available, overreaching its data to draw unwarranted conclusions. Most striking, and least justified, is its contention without substantiating patient data that patients who were assisted in suicide were receiving adequate end-of-life care. In fact, we know nothing about the physical, psychological, and existential needs of the patients requesting assisted suicide. We know little of the capabilities of the physicians who are responding to those requests. And we know nothing of the context in which these patients live and are cared for. We opposed the legislation, but since it was passed both advocates and opponents share a responsibility to see to it that the law is administered so as to best protect patients. If insufficient data is being obtained in a flawed monitoring process, everyone should be concerned. Limited Data The data OHD has collected is largely epidemiological: the assisted suicide cases were divided between men and women, the median age of the patients was sixty-nine, all the patients were white, all but two of them had cancer, and the patients who chose assisted suicide were more likely to be divorced or never to have married. Physicians participating in assisted suicide are not asked to provide OHD with significant medical information about their patients. They are merely asked to check off a list on an OHD form indicating that such statutory requirements as a written request for a lethal dose of medication, a fifteen-day waiting period, and consultation with another physician have been met. Only one line is provided for both diagnosis and prognosis, although a diagnosis of terminal illness and prognosis of death within six months are the essential requirements for assisted suicide in the state. The form does not inquire on what basis the physician made the medical diagnosis--for example, review of x-rays, written material, pathology reports, or other information. Nor are physicians asked to report on what basis they made the prognosis--what tables they have used, what experts they have consulted. The form does not even inquire as to the patient's reasons for requesting assisted suicide. The data do not make it possible to know what transpired in any particular case. To supplement the meager information required by formal reporting, OHD asked physicians who participated in assisted suicide to respond in person or by phone to a questionnaire that was also given to physicians of a comparison (control) group of patients who died of similar illnesses without assisted suicide. OHD does not tell us who asked the questions, what their training was, and whether any follow-up questions were asked. But the questionnaire (published on the Internet)[3] and the report show that this effort was also flawed. Missing medical information was not asked for or provided. In the absence of medical data, how does OHD reach its conclusion that patients received adequate end-of-life care? From the facts--derived from the physician questionnaire--that the proportion of patients who had advance directives and were enrolled in hospice programs was comparably high for both the case and comparison groups, and that neither worry about pain control nor financial concerns drove patients' requests for assisted suicide. But neither advance directives nor enrollment in a hospice program provides proof of competent assessment and treatment--the essential components of adequate care--any more than does patients' apparent silence about palliative care or financial concerns. Such figures cannot substitute for direct knowledge of patients and their illnesses. …