Ten years ago this month, Oregon enacted a law permitting physicians to prescribe a lethal dose of drugs to certain terminally ill patients, a practice often called physician-assisted suicide. The Death with Dignity Act, which took effect on Oct. 27, 1997, is the only law of its kind in the United States, making it an important and controversial milestone in the nation’s debate over end-of-life treatment.
A number of other countries, including the Netherlands and Belgium, allow physician-assisted suicide. In the U.S., several other states – including Vermont, Michigan and Washington – have considered measures to legalize physician-assisted suicide, but efforts to enact such laws have failed either in the state legislature or at the ballot box. The most recent attempt, in California, stalled in the state assembly earlier this year.
Oregon’s law applies only to patients who are terminally ill and likely to die within six months, a diagnosis that must be confirmed by two physicians. In addition, eligible patients must possess the mental capacity to give informed consent; cannot suffer from depression; and must sign a written declaration, in front of two witnesses, stating that they are mentally competent and acting voluntarily. Finally, while doctors may prescribe the lethal drugs, the dose must be administered by the patient. Between the time the statute was enacted in 1997 and the end of 2006, 292 terminally ill people had availed themselves of the right to end their lives, according to state records.
Opponents of physician-assisted suicide – including some medical groups, such as the American Medical Association; some disability-rights advocates; and some more socially conservative religious groups, such as the Roman Catholic Church, Orthodox Jews and evangelical Protestant denominations – argue that suicide is a tragedy, not a personal choice. Furthermore, they say, the practice will inevitably lead to abuses, such as patients who might be pressured to take their own lives by family members and others who wish to save money or end the burden of caring for someone with a debilitating illness. In addition, opponents say, doctor-assisted suicide devalues human life by sending a message to the broader culture that some people’s lives are worth less than others. Finally, they contend, physician-assisted suicide is at the top of a very slippery slope that could eventually lead to involuntary euthanasia of people who are severely handicapped or infirm.
Supporters of the practice include some more socially liberal Christian and Jewish religious denominations, some civil rights groups and some organizations that advocate on behalf of the rights of patients, particularly the terminally ill. These groups and others argue that “physician aid in dying” – calling the practice “suicide” unfairly imbues it with negative connotations, they contend – is not about forcing or pressuring anyone but rather is about giving people with no hope of recovery the option to end their lives before their physical pain becomes unbearable or before they fully lose control of their mental faculties. In addition, supporters argue, giving people the option to end their suffering does not devalue human life. On the contrary, they say, physician aid in dying promotes human dignity by allowing those in the last stages of potentially painful and debilitating illnesses to end their lives on their own terms.
Polls show that the country is divided on the issue of physician-assisted suicide, although the numbers differ somewhat based on how the survey questions are worded. For instance, a July 2005 poll conducted by the Pew Research Center for the People & the Press and the Pew Forum on Religion & Public Life asked half the participants about their views on the issue using one question and asked the other half a differently worded question. The survey found that 44 percent of respondents favored making it legal for doctors to “assist terminally ill patients in committing suicide” when the question was worded this way. But support for the practice rose slightly, to 51 percent, when people were asked if they favor making it legal for doctors to “give terminally ill patients the means to end their lives.”
The History of the Debate
The debate over the legal, ethical and political implications of death and dying is not new. But the modernization of health care in the 20th century dramatically changed the character of death and dying, and has cast this old debate in a different light. Beginning a little more than a century ago, people began to routinely die in hospitals rather than at home. More importantly, new technologies, such as the artificial respirator, allowed doctors to prolong life, often for substantial periods of time. At the same time, new drugs, such as morphine, allowed doctors to alleviate pain and to painlessly end patients’ lives.
By the 1950s, a small body of writers and thinkers in the United States and Europe began to argue in favor of allowing patients’ lives to be ended by the patients themselves, in the case of the terminally ill, or by their families and guardians, in the case of those on life support. These arguments gained wider acceptance in the 1960s as the civil rights movement, the sexual revolution and other social movements helped to expand notions of personal freedom.
In the 1970s the end-of-life debate vaulted onto the national stage thanks in large part to the highly publicized 1975 case of Karen Ann Quinlan, a 21-year-old New Jersey woman who had fallen into a coma and was judged to be in a “chronic persistent vegetative state,” unable to survive without the help of an artificial respirator. Efforts by Quinlan’s family to remove her life support were thwarted by her doctor, leading to a lawsuit and a ruling by the New Jersey Supreme Court that patients (and by extension their families) have a right to terminate life support.
In 1990, the right-to-die debate reached the U.S. Supreme Court in a case involving Nancy Cruzan, who had been in a persistent vegetative state for five years when her parents asked that her feeding tube be removed. In Cruzan v. Director, Missouri Department of Public Health, the court, in a 5-4 decision, implicitly recognized for the first time a constitutional right to refuse treatment in extraordinary circumstances.
In some ways, Cruzan presaged another high-profile case, that of Terri Schiavo, the severely brain-damaged woman whose husband and legal guardian fought against her parents to remove the feeding tube that was keeping her alive. Schiavo became a national media story from 2003 to 2005, as those favoring the “right to die” and those favoring the “right to life” battled over her fate in the courts, in the court of public opinion and even in Congress. But throughout the struggle, courts consistently ruled that Schiavo’s husband had the ultimate right to decide what his wife would have wanted, and with all appeals exhausted, she died on March 31, 2005, after her feeding tube was removed.
In the years between the Cruzan and Schiavo cases, a number of states held referenda on legalizing physician-assisted suicide for certain terminally ill patients. Voters rejected such measures in Washington state in 1991 and in California the following year. Although voters in Oregon first approved the Death with Dignity Act in 1994, it did not take effect until 1997, owing to court challenges and a second state referendum that unsuccessfully sought to nullify the act.
In the last decade, many of the high-profile battles over physician-assisted suicide have taken place in the courts. In 1997, the Supreme Court ruled in Washington v. Glucksberg that while the Constitution guarantees the right to refuse medical treatment, it does not give patients the right to assisted suicide. In 2006, the high court, in Gonzales v. Oregon, rejected an effort by the U.S. attorney general to use a federal drug law to prohibit doctors in Oregon from prescribing lethal doses of drugs to terminally ill patients under the Death with Dignity Act.
Supporters of physician-assisted suicide had hoped that the Gonzales v. Oregon decision would give their movement the momentum it needed to encourage other states to adopt laws similar to Oregon’s Death with Dignity Act. But, as the recent defeat of a doctor-assisted suicide bill in California shows, opposition to the practice remains strong, even in a state with a reputation for being at the forefront of new social trends.
Going forward, it is hard to know if and when another state or states will join Oregon. The only thing certain is that the debate over what is and is not an appropriate course of action when it comes to end-of-life decisions will continue for a long time to come.
This article was written by David Masci, Senior Research Fellow, Pew Forum on Religion & Public Life.