Margaret P. Battin

Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups

Background: Debates over legalisation of physician-assisted suicide (PAS) or euthanasia often warn of a “slippery slope”, predicting abuse of people in vulnerable groups. To assess this concern, the authors examined data from Oregon and the Netherlands, the two principal jurisdictions in which physician-assisted dying is legal and data have been collected over a substantial period. Methods: The data from Oregon (where PAS, now called death under the Oregon Death with Dignity Act, is legal) comprised all annual and cumulative Department of Human Services reports 1998–2006 and three independent studies; the data from the Netherlands (where both PAS and euthanasia are now legal) comprised all four government-commissioned nationwide studies of end-of-life decision making (1990, 1995, 2001 and 2005) and specialised studies. Evidence of any disproportionate impact on 10 groups of potentially vulnerable patients was sought. Results: Rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured (inapplicable in the Netherlands, where all are insured), people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS. While extralegal cases were not the focus of this study, none have been uncovered in Oregon; among extralegal cases in the Netherlands, there was no evidence of higher rates in vulnerable groups. Conclusions: Where assisted dying is already legal, there is no current evidence for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician-assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges.

Motivations for Physician-assisted Suicide

AbstractOBJECTIVE: To obtain detailed narrative accounts of patients’ motivations for pursuing physician-assisted suicide (PAS). DESIGN: Longitudinal case studies. PARTICIPANTS: Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors. SETTING: Participants’ homes. MEASUREMENTS AND RESULTS: We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS. CONCLUSIONS: Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient’s request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients’ concerns over time, and tailoring care accordingly.

Age Rationing and the Just Distribution of Health Care: Is There a Duty to Die?

The author analyzes the argument that a policy involving distributive justice in the allocation of scarce health care resources, based on the strategy of rational self interest maximation under a veil of ignorance (Rawls/Daniels), would result in an age rationing system of voluntary, socially encouraged, direct termination of the lives of the elderly rather than their medical abandonment. She maintains that such a policy would be a fair response only in a situation of substantial scarcity of resources that cannot be relieved without introducing greater injustices. Battin suggests that some of the current pressure on resources could be reduced by pruning waste and the expenses attributable to paternalistic imposition of treatment and to the practice of defensive medicine. She also advocates reconsideration of societal priorities assigned to various social goods.

Global Life Expectancies and the Duty to Die

Is there a duty to die? Consider the stark differences in life expectancy around the world, from as high as 80 in the richest nations to below 50 in the poorest. There are also stark global differences in access to health care. However, despite these stark differences, many theorists of distributive justice will reject the claim that inhabitants of the rich countries owe those of the poor countries anything at all, and certainly have no duty to die to conserve and redistribute health care resources in order to even these life expectancies out.

The irony of supporting physician-assisted suicide: a personal account.

Under other circumstances, I would have written an academic paper rehearsing the arguments for and against legalization of physician-assisted suicide: autonomy and the avoidance of pain and suffering on the pro side, the wrongness of killing, the integrity of the medical profession, and the risk of abuse, the “slippery slope,” on the con side. I’ve always supported the pro side. What this paper is, however, is a highly personal account of the challenges to my thinking about right-to-die issues. In November 2008, my husband suffered a C2/C3 spinal cord injury in a bicycle collision, leaving him ventilator-dependent, almost completely paralyzed, and in the hospital—but fully alert and profoundly self-reflective. What if he wanted to die? This paper draws from two multimedia presentations—file:///Users/margaretbattin/Documents/BROOKE’S%20ACCIDENT/The%20Salt%20Lake%20Tribune%20%7C%20Multimedia:%20Metamorphosis.webarchive and file:///Users/margaretbattin/Documents/BROOKE’S%20ACCIDENT/The%20Salt%20Lake%20Tribune%20%7C%20Multimedia:%20Learning%20to%20live%20again.webarchive—and personal material concerning quality of life (he’d rank at the bottom on the SF-36 and similar scales) and concerning autonomy (his own accounts, verbatim). This is a detailed portrait of a man whose life involves extraordinary suffering but also luminous experience some of the time. It only makes the question harder: What if he wanted to die?

Seven caveats concerning the discussion of euthanasia in Holland.

As the discussion of voluntary active euthanasia heats up in the United States (indeed, I believe it will be the major social issue of the next decade, replacing abortion in that role), increasing attention is being given to its practice in the Netherlands. Proponents of the view that the United States should legalize euthanasiat (as legislation being proposed by the Hemlock Society in California, Oregon, and Washington would do) often cite the Netherlands as a model of practice; opponents, on the other hand, claim that Dutch practice already involves widespread abuse and will inevitably lead to more. For the most part, these generalizations invite misunderstanding, and they often reflect only the antecedent biases of those who make them. I would like to offer a few caveats for bioethicists about to become embroiled in the discussion of euthanasia— caveats offered in the hope of contributing to better mutual understanding during the next decade, rather than to greater polarization. 1.There are no hard data about the practice of euthanasia in Holland.— Despite the policy that cases of active euthanasia are to be reported to the Ministry of Justice, only a very small fraction are: of the estimated annual 6,000 cases (itself a very loose estimate), in 1987 only 197 were actually reported and provide the only reliable set of data. There have been no comprehensive empirical studies of unreported euthanasia— nor, given its tenuous legal status (to be described below), is it clear how unbiased data could be obtained. Most discussions of euthanasia—both pro and con—appeal to anecdotes about specific cases, not to data covering the full range of cases. 2.Exaggerations are frequent.—It is also sometimes supposed that euthanasia is a routine, frequent, everyday practice in the Netherlands, a commonplace that happens all the time. On the contrary, euthanasia is comparatively rare. If the estimate of 6,000 cases a year is accurate

The Dreariness of Aesthetics (Continued), with a Remedy

[Twenty-Third Letter]. Accordingly, the aesthetic condition is supervenient upon the spontaneity of reason and sense enhancing their function by a superior judgment in human and scientific affairs. Play, I must insist, is never trivial. The balance of freedom and rule, of joy and restraint as evident in games, and sport is all one with the agility and speed of intellect in its highest reaches; for as intellect meets with perception, necessity puts aside its seriousness, because it grows light [Fifteenth Letter]. A joy of discovery, of surprise, enlivens our most somber inquiries. Man must needs keep before him his games as reminders; for if he is serious with the agreeable, the comprehensible, and the good, with Beauty he plays. Which is to say, he resolves a tension and achieves a state of equipoise, a subtle balance between tension and release, in effect, a discipline of expression of a kind familiar to performing artists-an artistry of living and of inquiry. That is aesthetic education. In concluding my epistle to a later age, I humbly beseech you as I did my Lord and patron in the ninth of my Letters: Live with your century, but do not be its creature; render to your contemporaries what they need, not what they praise.... Think of them as they ought to be when you have to influence them, but think of them as they are when you are tempted to act on their behalf.

Safe, Legal, Rare? Physician-Assisted Suicide and Cultural Change in the Future

Cultural change is well recognized in the recent history of death and dying. In the wake of Elizabeth Kubler-Ross’s 1969 work On Death and Dying, not only has it become socially acceptable to talk about death and dying with someone who is terminally ill, but, as traditional religious and legal strictures loosen, it is becoming possible for a person facing death to consider what role he or she wants to play in the forthcoming death. The United States has seen rapid evolution in attitudes and practices about death and dying over the last several decades, beginning with the early legal recognition in the California Natural Death Act (1976) of a patient’s right to refuse life-prolonging treatment in the face of terminal illness, expanding in increased public awareness of issues of personal autonomy in dying, raised by Derek Humphrey’s how-to book of lethal drug dosages, Final Exit, and blossoming in new sensitivity to physician roles in aiding dying, both in the maverick social activism of Dr. Jack Kevorkian and a New York grand jury’s refusal to indict the respected physician Timothy Quill. This process of cultural evolution has reached legal recognition: in 1997, the U.S. Supreme Court jointly decided the cases Washington v. Glucksberg and Vacco v. Quill, and while it held that physician-assisted suicide is not a constitutional right, it also left states free to make their own laws in this matter. Indeed, Oregon has made it legal for a physician to provide a terminally ill patient who requests it with a prescription for a lethal drug, thus bringing above ground the practical manifestation of a long process of cultural change.

Choosing the Time to Die: The Ethics and Economics of Suicide in Old Age

In recent discussions of distributive justice in health care, an ancient notion is again achieving currency: that when there are not enough resources to go around, the claims of the old — who no longer make economic contributions to society and who have already lived beyond a normal lifespan — diminish in comparison with the claims of the young. When not all needs and preferences can be satisfied, priorities in health care should go to those who remain productive and whose lives are not yet complete. This distributive issue about the relative strengths of claims of the elderly versus those of the young will be, no doubt, a central philosophical and economic issue for geriatrics in the 21st century — the topic to which this volume is addressed — and is very quickly becoming a pressing issue in the current century as well.

Should Pediatric Euthanasia be Legalized

Belgium recently legalized pediatric euthanasia. The Netherlands is considering a similar policy. Should they? Voluntary active euthanasia for adults at their explicit request has been legal in Belgium and the Netherlands since 2002. In those countries, acceptance of the practice for adults has been followed by acceptance of the practice for children. Opponents of euthanasia see this as a dangerous slippery slope. Proponents argue that euthanasia is sometimes ethically appropriate for minors and that, with proper safeguards, it should be legally available in appropriate circumstances for patients at any age. In this Ethics Rounds, we asked philosophers from the United States and the Netherlands, and a Dutch pediatrician, to discuss the ethics of legalizing euthanasia for children.