Retrospective Healthcare Policy Analysis: Oregon’s Death with Dignity Act

Professional Policy Analyst from the Normative Policy Analyses Approach

Retrospective Healthcare Policy Analysis: Oregon’s Death with Dignity Act

Oregon’s Death with Dignity Act was the legislated response to a highly controversial health policy debate regarding patients’ rights – specifically whether or not a patient has the right to die if they choose to do so (Altmann & Collins, 2007). While euthanasia and physician assisted suicide are not new topics, they did receive an increase in public and media attention during the early 1990s. Most notably Dr. Jack Kevorkian, who defied the law and assisted in 130 patient suicides, Dr. Kevorkian’s actions brought about increased media coverage on the topic of physician assisted suicide, which is a contributing factor as to why the Oregon’s Death with Dignity Act was conceived in the first place (Werth JR & Wineberg, 2005). On the one side of the spectrum were advocates of physician assisted suicide who maintained that it was an infringement on patients’ rights to deny them aid in dying, and inhumane to make people suffer when diagnosed with a terminal illness (Merino, 2012). On the other side were critics who concluded that physician assisted suicide was a breach of medical ethics, and morally unacceptable because it devalued human life. Furthermore, these critics found that assisted suicide was not valid because there were alternative solutions, such as improving physician training on pain management, and end of life care (Merino, 2012). In 1997, the decision was made, to sign into law, the Oregon Death with Dignity Act (ODWDA), which allowed Oregon physicians to prescribe medicine to specific patients fully knowing that consuming it would bring about the patient’s death (Altmann & Collins, 2007). This law was designed to fulfill two goals: decrease the pain and suffering of terminally ill people, and uphold a patient’s right to choose to end their life under certain circumstances (Werth JR & Wineberg, 2005; Altmann & Collins, 2007).

Prior to analyzing this policy, it is essential to clarify relevant terms and stakeholders. The definitions of key terms are as follows:

• Euthanasia: The intentional and deliberate act that results in the death of a patient at their request (e.g. injecting a patient with a lethal dose of morphine) (Altmann & Collins, 2007); and
• Physician Assisted Suicide: A physician providing a means for the patient to end their own life (e.g. prescribing a lethal dose of drugs for a patient to self-administer) (Altmann & Collins, 2007).
Stakeholders include physicians, nurses and other healthcare professionals who work intimately with patients, politicians in charge of making end of life laws, patients suffering from terminal illnesses and their family members, and religious leaders who may hold ethical objections. In this paper, I intend to analyze the development and selection process used to implement the ODWDA and describe its implementation and results. I will accomplish this by candidly looking at the ODWDA, weighing the alternatives, analyzing how well the policy was upheld, and whether or not ODWDA accomplished its intended goals.

Description of policy development & selection process

The overall goals and objectives of the ODWDA were twofold. First, this policy was designed to relieve pain and suffering. Second, the policy was implemented to uphold individual patient’s rights by enabling the terminally ill to end their own lives with physician assistance (Altmann & Collins, 2007). As shown, the key stakeholders include physicians who were responsible for prescribing the lethal medicine, nurses and other healthcare professionals, malpractice insurance companies, interest groups, state agencies, the public, politicians, and most importantly the terminally ill patients and their family members. Oregon state residents voted 51.31% to 48.69 % in favor of the ODWDA bill during the 1994 general elections (Oregon Health Authority, 2016). Later, politicians, such as U.S. Attorney General Ashcroft tried to repeal the bill; however, all attempts were blocked (Altmann & Collins, 2007). Opponents, for the most part, include some religious leaders, politicians, and individuals who hold moral and ethical objections.

Many groups and individuals proposed alternative options. One possible alternative was to improve physicians and caregivers’ education and training regarding end-of-life treatment options and pain management (Altmann & Collins, 2007). Another proposed alternative solution was to increase services aimed at end-of-life care, such as hospice and palliative care (Altmann & Collins, 2007). Moreover, some opponents to the ODWDA argued that many patients were not aware of these alternative end-of-life measures, and, therefore, should have been made aware of the alternative end-of-life options that were potentially available to them (Werth JR & Wineberg, 2005). An acceptable way to measure these alternative options is to analyze whether or not they meet the two, primary objectives of the ODWDA (to decrease pain and suffering and uphold patients’ rights). All three of the alternative solutions – improve physician’s knowledge of pain management for the terminal ill patient, an increase in hospice and palliative care services, and more and better patient education programs on end-of- life options – work to decrease pain and suffering. However, none of these alternative solutions addresses the concern regarding a terminally ill patient’s right to choose to end their own life. Only the ODWDA meets both criteria and, therefore, it should be viewed as the preferred option.

Concerning the costs of the ODWDA, the Oregon Health Authority (2016) reported, “We do not collect cost data. However, direct costs for participation in the Act might include office calls relating to the request, a psychological consult (if required), and the cost of the prescription”. Other costs to consider include the cost of setting up the Death with Dignity system in Oregon, but, again, no official data is available (Oregon Health Authority, 2016). In general, the costs are thought to be relatively minimal and of a great benefit to reducing the financial burden to terminally ill patients’ families in comparison to keeping a terminal patient alive and comfortable for a prolonged period of time (Merino, 2012).

Groups most directly impacted by the ODWDA include terminally ill patients and their family members, nurses caring for the patients,and medical professionals in charge of administering the lethal dosages of prescriptions . Groups indirectly affected included religious leaders, politicians, ethicists, legal professionals, and hospital administrators. Starr’s Policy Trap does not apply to this policy. However, there are many legal and political issues that have to be considered, such as whether or not it is legal and ethical for a physician, who takes the Hippocratic Oath, to help intentionally bring about a terminally ill patient’s death. However, over the past 20 years since the ODWDA has been put into law, all attempts to overturn it from legal and ethical arguments have been dismissed by the courts (Altmann & Collins, 2007; Merino, 2012).

One equity issue that should be noted is socio-economic status and ODWDA. Some opponents have maintained that poorer individuals might feel obligated to resort to physician-assisted suicide to relieve their families of the financial burden their care creates. Moreover, it is assumed that all patients who choose the option of physician assisted suicide are acting on their own accord; however, some evidence suggests that family pressure might play a role in influencing their decisions (Werth JR & Wineberg, 2005). Nonetheless, several interest human rights groups have done an excellent job of promoting the ODWDA, and showing its benefits for terminally ill patients to the public (Merino, 2012). Please see Appendix for an authorizing environmental chart.

Implementation The ODWDA includes many criteria that make monitoring and evaluating the process possible. For instance, to request a prescription for lethal medication in order to end their life, the patient must be at least 18 years old, a resident of Oregon, capable of making decisions on their own behalf, diagnosed with a terminal illness, make two or more verbal requests to their physician separated by a period of 15 days, and provide a written request (ORS 127.800–897). While the provisions and steps are clearly defined, skeptics note that there is little oversight to ensure that the policy is properly implemented and has generated the intended effects. For instance, Werth and Wineberg (2005) point out, “First, the criteria for voluntariness are unstated and merely signing a piece of paper does not prove voluntariness. Second, there is nothing to prevent the physician from suggesting assisted death to the patient” (p. 20). Also, few checks and balances are in place to make sure that the patients are, indeed, counseled on their alternative options. Moreover, there is some concern regarding influencing factors that could result in patients feeling obligated to make a certain decision (Werth JR & Wineberg, 2005). Therefore, more research needs to be conducted to ensure that the policy is being properly implemented as it was originally intended. Although minor revisions were made to the ODWDA act, in general, it has not undergone any major revisions. Although some politicians, including Attorney General Ashcroft, have been at battle with the ODWDA, in different levels of court, ultimately, when the case was brought to the US Supreme Court, it was ruled to be valid. Therefore, despite some opposition, the law is still in effect today (Altmann & Collins, 2007).

Conclusions and Recommendations

In general, the ODWDA has met its two, primary objectives. It has upheld patient rights and decreased undo pain and suffering. However, it is not perfect and has its downfalls. Corrective recommendations include a more robust means of ensuring voluntariness, such as two or more medical professionals consulting with the patient, alone, without the patient’s family present. Requirements that are stricter and more measurable regarding counseling with psychologists and educating the patient on alternative solutions, such as hospice and palliative care. More research with regard to finding new methods of alleviating the financial burden of long-term treatment, to discourage cost-related factors from playing a role in a terminally ill patient’s decision. The ODWDA is a groundbreaking health care policy that will inevitably influence other states as to their own policies regarding the treatment and options available to terminally ill patients. Despite the legal hurdles, the ODWDA has faced since its implementation, and its varied opponents, in the eyes of the terminally ill patients that have chosen to end their lives in Oregon, the act has been successful. In the United States, this issue is still a debatable topic. Only time will tell whether or not individual states or the federal government will implement a similar act for terminally ill patients.

References

Altmann, T. K., & Collins, S. E. (2007). Oregon's Death with Dignity Act (ORS 127.800–897): A Health Policy Analysis. Journal of Nursing Law, 11(1), 43-52.

Merino, N. (2012). Assisted suicide. Detroit: Greenhaven Press.

Oregon Health Authority. (2016). FAQs about the Death with Dignity Act. Retrieved 1 February 2016, from http://Oregon Public Health Division healthoregon.org/dwd Page 1 of 6 FAQs about the Death with Dignity Act

Oregon Death with Dignity Act (1995). ORS 127.800–897.

Werth JR, J., & Wineberg, H. (2005). A critical analysis of criticisms of the Oregon Death with Dignity Act.

Appendix

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