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Physician assisted suicide is a hotly contested topic in the United States and overseas. In 1997, the United States Supreme Court made a major decision that lead to the enactment of the Death with Dignity Act in the state of Oregon. This paper analyzes the obstacles to the implementation of the act and the criticisms against the act.
Obstacles in Implementation
The Oregon Death with Dignity Act was first passed by voters in November of 1994 following a referendum in the state. However, the act could not come into effect following a class action suit that challenged the facial validity of the act. The class action group consisted of patients, physicians and residential care facilities who alleged that the act violated the equal protection and due process rights as embodied in the constitution (Park, 1998).In their argument, the plaintiffs argued that the act failed to protect vulnerable patients who could seek assisted suicide due to coercion or undiagnosed depression(Cohen-Almagor & Hartman, 2001). Following this suit, a preliminary injunction was granted by the United States District Court in the district of Oregon (Park, 1998). In making this decision, the District Court argued that the act breached the Equal Protection Clause embodied in the Fourteenth Amendment of the constitution (Cordaro, 2002).The court granted the summary judgment motion proposed by the plaintiffs by arguing that the act breached the Equal Protection Clause in the constitution. The Court of Appeals contended that implementation of this act would result in patient discrimination as terminally ill patients would be able to get assisted suicide while other patients could not (Park, 1998). The injunction was lifted by the Ninth Circuit Court in 1997 based on procedural grounds as federal courts did not have jurisdiction to hear the matter (Cordaro, 2002). Despite this, the act could not be enacted as the state awaited the decisions of the Supreme Court in Vacco v.Quill and Washington v. Glucksberg, where it was decided that physician assisted suicide lacked rights in the constitution (Cohen-Almagor & Hartman, 2001). Following this decision, a certiorari was presented before the Supreme Court, which was denied allowing for a referendum on the repeal of measure 51, which was aimed at overturning the act, to take place (Cardaro, 2002). The referendum rejected the repeal by a margin of 60 percent to 40 percent leading to the retention of the Death with Dignity Act.
The federal government under the DEA also intervened on this decision by arguing that doctors who prescribed drugs to terminally ill patients for assisted suicide violated the Controlled Substances Act guidelines and risked revocation of their registrations (Cordaro, 2002). According to the DEA, prescription of drugs for assisted suicide did not serve a legal medical purpose. The Attorney General challenged the DEA by contending that it did not have the right to prosecute or revoke a physician’s registration for doctors who assisted in suicide by complying with Oregon law (Cordaro, 2002). This decision was based on the idea that since Oregon considered assisted suicide as a legal medical practice, federal laws lacked basis for disagreements. After all these legal battles, the Death with Dignity Act was enacted into law in 1999 in the state of Oregon. Physicians using this act are required to comply with Oregon laws on the issue.
Criticisms against the Law after Implementation
The Death with Dignity Act authorizes physicians to give federally approved prescriptions for self administered lethal injections to terminally ill patients with a life expectancy of less than six months, who are mentally competent to end their life in a dignified manner (Cohen-Almagor & Hartman, 2001). In addition, physicians are required to write the prescriptions in by complying with the act to prevent professional discipline and criminal or legal penalties. The act faces criticisms in terms of its implementation.
In Oregon, the criterion for physician assisted suicide is based on diagnosis of a terminal illness whose prognosis is less than six months of living. Therefore, intolerable and un-relievable suffering is not a requirement for assisted suicide in the Oregon law (Hendin, Foley & White, 1998). The criterion in the Oregon act unintentionally allows physicians to assist in suicide without conducting inquiry into the social, psychological, and medical concerns associated with assisted suicide (Hendin & Foley, 2008). Such inquiry provides pertinent information that can be used in relieving the suffering of patients using alternative means rather than assisted suicide. In Oregon, when a patient makes a request for assisted care, the physician indicates feasible alternatives such as hospice and palliative care. However, the physician is not required to determine how to alleviate emotional or physical suffering in a terminally ill patient. Without this knowledge, the physician cannot present feasible alternatives to a patient. Hence, attention shifts from alleviating the pain of a dying patient to meeting the statutory requirements for assisted suicide (Hendin & Foley, 2008). Thus, the criterion considered by the death with dignity act, may lead to the death of patients whose suffering could have been alleviated by other alternatives.
In the Death with Dignity Act, assisted suicide is acceptable in medical illness. It is imperative to understand that there are patients who get suicidal thoughts due to the terminal illness. Although patients with terminal illnesses may wish to die due to pain and lack of support from the family, research evidence indicates that hopelessness as related to depression is a significant factor in predicting a death wish (Chochinov et al, 1998). Hence, a patient requesting suicide needs to undergo psychiatric assessment to establish if one is seriously depressed or mentally incompetent, which disqualifies one for physician assisted suicide. Indeed, it is argued that approximately two thirds of patients requesting assisted suicide are depressed (Hendin, Foley & White, 1998), a condition that can be managed using alternative therapies instead of suicide. According to Hendin and Foley (2008), the Oregon law has not established this requirement for patients seeking assisted suicide. Therefore, the physicians lack guidance on determining the level of impairment related to depression as a way of preventing assisted death.
Decisions related to end of life are supposed to be taken voluntarily and without coercion from anyone. Although the law in Oregon requires that a patient requesting for physician assisted suicide should give voluntary informed consent based on their mental competence, it is lacking in safeguards to ensure that this takes place (Hendin & Foley, 2008). Specifically, the law has failed to stipulate the assessment criteria needed for voluntary consent in request for assisted suicide (Hendin, Foley & White, 1998). In addition, the law does not require the patient to inform family members about their request for physician assisted suicide. Thus, a patient may make such a decision because one wants to alleviate emotional or financial suffering for the family. In this way, voluntary consent is circumvented. In addition, failing to inform the family prevents it from expressing care and concern that may change an individual’s decision regarding suicide.
The Death with Dignity Act places limited liability on physicians as they are immune from criminal and civil penalties provided one acts in good faith. The reporting systems are weak implying that if a physician acts negligently, one cannot face the consequences. It is suggested that there is lack of enforcement mechanism when the physician fails to comply with guidelines for reporting all the cases involving prescription for assisted suicide medication (Hendin & Foley, 2008). In particular, the reporting procedures do not require the physician to provide information on a patient’s reasons for making requests for assisted suicide or what guided the doctor’s diagnosis or prognosis related to the terminal medical condition(Hendin,Foley & White,1998). Furthermore, the practice of assisted suicide is shrouded in secrecy and anonymity prevents assessment of physician conduct and increases the patients’ vulnerability. Therefore, this reduces accountability in terms of ascertaining that the physicians meet the practice standards.
In conclusion, the physician assisted suicide law in Oregon has assisted patients and doctors in making end of life decisions for the terminally ill patient. Although the law has been in implementation since 1998 after overcoming constitutional and legal obstacles, various criticisms have emerged. Specifically, the criticisms are based on the criteria for assisted suicide, patient voluntary and informed consent, psychiatric evaluation and physician accountability. All these issues bring out the weaknesses of the act in addressing end of life decisions for patients. Therefore, there is need for change through reviewing and amending the act to protect patients in this acquired right over their end of life decisions.