Editorials

Oregon's plans to legalise suicide assisted by a doctor

Oregon voters' approval of Ballot Measure 16 in last November's election marked the first time that suicide assisted by a doctor had been legalised anywhere in the world. Although an injunction currently bars the law, its passage by the electorate suggests that American attitudes towards suicide assisted by a doctor are shifting gradually towards acceptance.¹ Surveys suggest that the attitudes of American doctors^{2 3 4 5} are also shifting--as they are in many other countries.

If the injunction is lifted the new law in Oregon will allow a primary care doctor to prescribe a lethal dose of drugs for a terminally ill adult patient who asks for it in order to give himself or herself an overdose. The doctor has the right to decline. The patient must be a resident of Oregon who is competent, informed, and expected to die within six months. A second doctor must confirm the prognosis. The patient must make two oral requests, separated by a 15 day waiting period, and one written request. If the doctor suspects that the patient has a mental disorder affecting judgment the doctor must refer him or her to a mental health professional. The doctor must ask the patient to disclose his or her intentions to family members, although the patient is not required to do so. Insurance companies may not withhold death benefits when patients comply with the law. Doctors who act in good faith with the law are protected from professional discipline and legal liability. Doctors must report participation to the state health division.⁶

During the election campaign, debate was highly polarised and the issue was largely framed in terms of religion and patients' rights. The Catholic church and most Protestant denominations strongly opposed legalisation on moral grounds. National Right-to-Life, an organisation that is strongly against abortion, was also active in the campaign against Ballot Measure 16. The American Medical Association officially opposed the measure and publicly criticised its state affiliate, the Oregon Medical Association, for failing to take a stand against it.

On 8 November 51% of Oregonians voted in favour of the measure and 49% voted against it. One day before the law was to go into effect on 8 December two doctors and several terminally ill patients, represented by a lawyer from national Right-to-Life, filed a class action lawsuit claiming that the law discriminates against terminally ill patients and people with religious objections.⁷ A federal judge has issued a preliminary injunction pending a trial to review the constitutional questions. Both sides have indicated that the decision will be appealed against regardless of the outcome. This suggests that the court process may continue for quite a long time and may reach the level of the United States Supreme Court.

Although the legal fate of the statute has not been decided, its approval by voters raises several issues. Although anecdotal reports confirm that suicide is sometimes assisted by doctors in the United States, this is illegal.^{2 4} Would legalisation in Oregon bring the practice into the open? Several factors suggest that, even in Oregon, doctors might continue to help patients to die in secrecy. Despite legalisation, if suicide assisted by a doctor remains contrary to professional codes then doctors who openly participate may risk ostracism by colleagues. Catholic health care systems in Oregon have already announced that they will not offer suicide assisted by a doctor and that they will discipline doctors who participate within their facilities.

Threats from "right to life" activists

Doctors might also be reluctant to write lethal prescriptions openly, even if it was legal, because of concerns for both patients' privacy and their own. For years the American antiabortion movement has drawn negative public attention to doctors who perform abortions, although abortions are accepted medical practice in the United States. Antiabortion activists often demonstrate outside doctors' offices, clinics, and homes. Recent shootings of doctors and innocent bystanders inside and outside abortion clinics have raised doctors' concern beyond privacy to personal safety and the safety of their families.⁸ The prominence of "right to life" activists among opponents of suicide assisted by a doctor could therefore be a serious deterrent to openness.

On the other hand, legalisation could serve to increase openness about care at the end of patients' lives within the privacy of the doctor-patient relationship. Since the vote patients' requests for lethal prescriptions seem to have increased, as has doctors' responsibility to probe the unmet needs that cause these patients to seek an earlier death.⁹ The result of the election indicates grave public dissatisfaction with doctors' commitment and skill in managing the varied forms of suffering that commonly accompany terminal illness. We hope that it will encourage doctors to become more ready to discuss openly issues concerning the end of life and to improve skills in providing supportive care to dying patients.

Approval of Oregon's Ballot Measure 16 signals a shift in American attitudes towards suicide assisted by a doctor. Legalisation will probably lead to greater openness between doctors and their patients, but other social forces have made it necessary to protect privacy. These factors may force assisted suicide to remain a covert practice.

Assistant professor of medicine, Division of Geriatrics Director, Center for Ethics in Health Care Oregon Health Sciences University, Portland, OR 97207, USA

Melinda A Lee, Susan W Tolle 

1. Blendon RJ, Szalay US, Knox PA. Should physicians aid their patients in dying? The public perspective. JAMA 1992;267:2658-62. [Medline]
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6. Ballot Measure 16. Oregon voters' pamphlet. Portland: Multnomah County Elections Division, 1994.
7. Lee et al v State of Oregon et al. USDC No 94-6467-H0 (D Or).
8. Hodgson JE. Violence versus reproductive health care. BMJ 1995;310:547-8. [Free Full Text]
9. Council on Ethical and Judicial Affairs. Physician-assisted suicide. In: Code of medical ethics reports (report 59). Chicago: American Medical Association, 1994:274.