Adventures in Old Age

A candid look at aging, old age, and eldercare.

Assisted Suicide In the United States? Go West Old Man

Suicide is the ultimate medical cost container.

If you want to end it, but you're too ill or don't have time to travel to the Netherlands, there is Oregon and its Death with Dignity Act. This law-enacted by ballot iniative in 1994-does not go as far as the Dutch law, because it is limited to terminally ill patients. (Washington, more recently, passed a similar ballot initiative in 2008.) Intractable physical or psychic pan sufferers need not apply to die, as they can in the Netherlands. Oregon also doesn't allow your physician to assist you directly to die. The law simply allows your physician to prescribe lethal meds for you to take in the privacy of your own home-Socrates style, downing your hemlock with your disciples gathered around while you expound on the meaning of life as you descend into oblivion. You can go to the Oregon state government web page and download the form-"Request for medication to end my life in a humane and dignified manner"-to apply for the lethal dose. It's kind of a penultimate testament in which you certify that you are of sound mind-if not of body. The law is silent about people who cannot administer the dose to themselves, although no doctor need be present: "Open up, Mom. Here are your last meds." Something about me loves the fact that the Web page asks you to check with your health insurer to see whether this is a covered procedure. Covered procedure? You bet. Suicide is the ultimate medical utilization cost saver.

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For all the political fuss about this law, terminally ill people are not exactly beating down death's door to get their lethal meds. Since the law was enacted, as of 2007, a total of 292 patients had kicked the legal suicide bucket. In 2006, for example, under the provisions of the law, there were forty-six deaths per ten thousand-0.0046 percent. In contrast, 2 percent of deaths in the Netherlands fall under the provisions of its euthanasia law.

This does not mean the law is unpopular in Oregon. A state referendum to repeal it went down when 60 percent of the electorate voted to keep it on the books. Perhaps this means that people like the idea that they can end it if they really want to-even if they aren't planning on it. Perhaps it means that it's harder to get something off the books than to get it on the books in the first place. Several other states have failed to pass physician-assisted suicide voter referendums. Others have failed to enact legislation, and a few State Supreme Courts have decided that physician-assisted suicide is unconstitutional-but not the United States Supreme Court. In 2006, by a 6-3 margin, it held that was was none of Attorney General John Ashcroft's legal business to interfere in a medical procedure. The Supremes ruled that it was up to the states, on an individual basis, to decide if you can get the hemlock prescription.

So if you are terminally ill in Oregon, and want to die, lucky you. But if you are not in Oregon, or Washington, are you out of luck? Not necessarily. It's not as easy as buying crack on your local street corner, but it's not impossible to get the benefits of Oregon's law without being an Oregonian.

If you are too cowardly or do not have the means or capability of killing yourself, there is a fair amount of bootleg physician-assisted suicide outside Oregon. Prior to Washington's enactment of its own Death With Dignity Law, a survey found that 26 percent of physicians in that state had received a request for assisted suicide, and that two-thirds of the physicians receiving a request had granted the wish. Among AIDS physicians, the requests are dramatically higher. A survey of San Francisco physicians treating AIDS revealed that 98 percent had been asked for suicide assistance. On average, about 4 percent of the surveyed had granted such requests, and some physicians had granted dozens of requests.

Should we try to dissuade medically or psychically distressed people from killing themselves? There is the argument that people who are depressed who receive treatment are likely to decide against suicide. This argument is worthy of consideration as long as we don't fall into the circular reasoning trap that anyone who wants to commit suicide is depressed.

In "Physician-Assisted Suicide: The Influence of Psychosocial Issues," published in the journal Cancer Control in 1999, an oncologist and a psychologist, William Breitbart, MD, and Barry D. Rosenfeld, PhD, write, "many terminally ill patients are likely to be experiencing a depression that may be both treatable as well as temporary." Temporary, of course, is a relative term when you are terminally ill, but Breitbart and Rosenfeld accept the idea that not all terminally ill people are depressed and that depression alone does not mean you are incapable of making a competent decision about your own death. They recommend the aggressive treatment of pain and depression, and then reevaluating whether the patient still wants to cash in his chips.

The recommendation for the aggressive treatment of depression-with the use of either meds or psychotherapy-does raise the question whether antidepressant medications could cloud your competent suicidal judgment and whether psychotherapy is merely a sophisticated way to talk you out of it. Because the diagnostic criteria for depression include a desire to end life, we have to be careful to exclude that as a criterion when an otherwise competent person but suffering person requests assistance. And this reasoning leaves aside the deeper question whether depression-even if we can validly think of it as an illness-can be an intractable illness, as intractable as severe physical pain, and be in itself the source of a reasonable desire to die. I've met some people for whom depression is a deeply embedded part of their being. People who have had every treatment imaginable-pills, psychotherapy, electric shock therapy-and want to end their suffering. Who am I to say no to them? To request them to spend some weeks, months, years talking to me instead?

"I'm depressed. I just want to end it," one nursing home resident said to me.

"Are you unhappy because you're sick and in this nursing home?"

"No. I've felt that way most of my life, but my obligations to my family kept me alive. Now, they're all set and I see no reason to go on here or anywhere else."

George Costanza said: "I love a good nap, sometimes it's the only thing getting me out of bed in the mornings." Some people feel that way about life and the dirt nap.

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This post was adapted from my book, Nasty, Brutish, and Long: Adventures In Eldercare(Avery/Penguin, 2009), which was a Finalist for the 2010 Connecticut Book Award. Click here to read the first chapter It provides a unique, insider's perspective on aging in America. It is an account of my work as a psychologist in nursing homes, the story of caregiving to my frail, elderly parents--all to the accompaniment of ruminations on my own mortality. Thomas Lynch, author of The Undertaking, calls it "A book for policy makers, caregivers, the halt and lame, the upright and unemcumbered: anyone who ever intends to get old."

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Ira Rosofsky, Ph.D., is a psychologist in Connecticut who works in eldercare facilities and the author of Nasty, Brutish, and Long: Adventures in Old Age and the World of Eldercare.

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