Concerns about assisted suicide include hiding malpractice and "lazy doctoring."

http://helenair.com/news/opinion/readers_alley/against-physician-assisted-suicide/article_7b17e3b6-9b57-11e3-ab51-001a4bcf887a.html

I am a general medical practitioner, with 30 years experience. I was glad to see that Montanans Against Assisted Suicide has decided to appeal its case with the Montana Medical Examiner Board to the Montana Supreme Court. My hope is that the appeal will end the controversy about assisted suicide possibly being legal in Montana.

My concerns about legalizing assisted suicide include that it will encourage "lazy doctoring." I say this because it is easier for a doctor to write a prescription (to end the patient's life,) as opposed to doing the sometimes hard work of figuring out what is wrong with a patient and providing treatment. I am also concerned that legalization will give bad doctors the opportunity to hide malpractice by convincing a patient to take his or her life.

The American Medical Association, Ethics Opinion No. 2.211, states: "Physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks."

I agree with this statement. Allowing legalization of physician-assisted suicide in Montana will compromise and corrupt my profession. Legalization will also put the lives and well-being of my patients at risk.

Carley C. Robertson, MD
Havre MT

New Swiss Study Misses the Obvious: Wealthy Older People May Have been Targeted for Their Money.

"How sharper than a serpent's tooth it is
To have a thankless child!"

- William Shakespeare
King Lear Act 1, Scene 4

Below is post from Medical Xpress, regarding a new study finding that people from wealthier areas are more likely to die from assisted suicide.  The post also says:  "Having children was associated with a lower risk of assisted suicide in younger people, although not in older people."  The "inheritance factor" is completely overlooked.

More educated people from wealthier areas, women, more likely to die from assisted suicide

http://medicalxpress.com/news/2014-02-people-wealthier-areas-women-die.html

Researchers in Switzerland, where assisted suicide is legal, have conducted a study – published online in the International Journal of Epidemiology today – that shows assisted suicide is more common in women, the divorced, those living alone, the more educated, those with no religious affiliation, and those from wealthier areas.

While euthanasia is prohibited in Switzerland, the penal code states that assisted suicide is legal if no selfish interests are involved. Assisted suicides in Switzerland involve volunteers working for "right-to-die" associations. The role of physicians is restricted to assessing the decisional capacity of the person requesting assistance and to prescribing the lethal drug. Notably, the person requesting assistance does not need to have a terminal illness.

In this study Professor Matthias Egger and colleagues at the University of Bern linked data from three right-to-die organisations to the Swiss national Cohort, a longitudinal study of mortality based on linkage of census and mortality records. The study followed those aged 25 to 94 from 1 January 2003 until their death, emigration, or the end of the study: a total of 5,004,403 people. Anonymous data on 1,301 cases of assisted suicide between 2003 and 2008 were provided by the three right-to-die organisations.

Study findings showed assisted suicide was more common in women than men, in people with secondary or tertiary rather than compulsory education, in those living alone, and in those with no religious affiliation. The rate was also higher in urban compared to rural areas, in wealthier neighbourhoods, and in the French rather than German or Italian speaking areas of the country. Having children was associated with a lower risk of assisted suicide in younger people, although not in older people.

In 84% of cases the death certificates listed at least one underlying cause of death. In the age group 25-64 years the majority had cancer ( 57%), followed by diseases of the nervous system (21%). Eleven individuals had a mood disorder listed as the first underlying cause, and three had another mental or behavioural disorder. For all causes, except Parkinson's disease, the percentage of assisted suicides was higher in women than men. In the 65-94 years age group, cancer was again the most common underlying cause (41%), followed by circulatory (15%) and diseases of the nervous system (11%). Thirty people had a mood disorder, and six had another mental or behavioural disorder.

Dr Egger says, "Our study is relevant to the debate on a possibly disproportionate number of assisted suicides among vulnerable groups. The higher rates among the better educated and those living in neighbourhoods of higher socio-economic standing does not support the 'slippery slope' argument but might reflect inequities in access to assisted suicide. On the other hand, we found a higher rate among people living alone and the divorced. Social isolation and loneliness are well known risk factors for non-assisted suicides and our results suggest that they may also play a role in assisted suicide. Also, the observation that women die more frequently by assisted suicide than men is potentially of concern. Interestingly, though, studies from the Netherlands and Oregon in the USA reported more men than women among assisted deaths."

16% of death certificates did not register an underlying cause. A previous study of suicides by two right-to-die organizations showed that 25% of those assisted had no fatal illness, instead citing "weariness of life" as a factor. In 2013 the European Court of Human Rights asked Switzerland to clarify whether and under what conditions individuals not suffering from terminal illnesses should have access to help in ending their lives, suggesting that Switzerland should more precisely regulate assisted dying.

Dr Egger says: "We believe that such new regulation should mandate the anonymous registration of assisted suicides in a dedicated database, including data on patient characteristics and underlying causes, so that suicides assisted by right-to-die associations can be monitored."

Explore further: Swiss groups fear study undercuts assisted suicide

More information: 'Suicide assisted by Right-to-Die Associations: Population based cohort study' by Nicole Steck, Christoph Junker, Maud Maessen, Thomas Reisch, Marcel Zwahelen, and Matthias Egger, International Journal of Epidemiology, DOI: 10.1093/ije/dyu010

Journal reference: International Journal of Epidemiology

Margaret Dore writes the New Hampshire Judiciary Committee: Vote "No" on HB 1325

Madame Chair and Members of the Committee,

During the recent hearing on assisted suicide, I mentioned that there had been a significant increase in other suicides in Oregon after assisted suicide legalization.  This is consistent with a suicide contagion (legalizing and thereby normalizing one type of suicide encouraged other suicides). 

Of course, a correlation does not prove causation. 

However, as set forth below, there is a significant statistical correlation between the two events.  Moreover, the financial cost to Oregon from the other suicides is enormous.  Please see the data below:

Oregon's assisted suicide act went into effect in 1997. See top line at this link: http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/index.aspx

By 2000, Oregon's regular suicide rate was "increasing significantly"  See http://www.oregon.gov/DHS/news/2010news/2010-0909a.pdf ("After decreasing in the 1990s, suicide rates have been increasing significantly since 2000")

In 2010, Oregon's other suicide rate was 35% above the national average.  http://maasdocuments.files.wordpress.com/2013/02/oregon-suicide-info_001.pdf

In 2012, the most recent report, Oregon's other suicide rate was 41% above the national average.  http://choiceisanillusion.files.wordpress.com/2014/02/oregon-suicide-report-2012-through-2010-pdf.pdf  Moreover, this report, page 3, states:

"Suicide is the second leading cause of death among Oregonians ages 15-34, and the 8th leading cause of death among all ages in Oregon.  The cost of suicide is enormous.  In 2010 alone, self-inflicted injury hospitalization changes exceeded 41 million dollars; and the estimate of total lifetime cost of suicide in Oregon was over 680 million dollars.  The loss to families and communities broadens the impact of each death."

The report, itself, does not address the possible influence of assisted suicide legalization.  But, again, the significant statistical correlation is there.  The cost to the state is enormous.

Please feel free to contact me for any further information.

Thank you.

Margaret Dore
Law Offices of Margaret K. Dore, P.S.
www.margaretdore.com
www.choiceillusion.org
1001 4th Avenue, 44th Floor
Seattle, WA  98154
206 389 1754 main line

Dr. Toffler Writes the New Hampshire Judiciary Committee: "Vote NO on HB 1325"

Dear Members of the Committee:

I am a doctor in Oregon where assisted suicide is legal.  As a professor of Family Medicine and practicing physician in Oregon for over 30 years, I write to urge you to not make Oregon's mistake and vote No on HB 1325.

I understand that there was a question during your recent hearing regarding the appropriateness of suicide prevention with a terminal patient.  Terminal patients, like other patients, will sometimes express suicidal desires and ideation.  Terminal patients, like other patients do not necessarily mean it and may even want you to say "no."  They may also be clinically depressed, i.e., colloquially not in their "right minds."  With this situation, suicide prevention is not only appropriate, but necessary to provide good medical care and to avoid discrimination based on the patient's quality of life as perceived by the doctor.

In my practice, I have had well over twenty patients ask me about participating in their suicides or giving them information about assisted suicide.  In every case I have explored the issues behind their request, and then assured them that I will provide their medical care to the best of my ability. At the same time, I also strive to reflect and convey their inherent worth and my inability to collude with their request to help end their life.  I remember one case in particular, the man's response was "Thank you." 

To read more about that case and some of my other cases in Oregon, please read my statement to the BBC, since re-titled as "What do People Mean When They Say they Want to Die?"  http://www.choiceillusion.org/p/what-people-mean_25.html

Please vote No on HB 1325,

Thank you,

William L. Toffler MD
Professor of Family Medicine
3181 SW Sam Jackson Park Road
Portland, OR 97239
503-494-5322
503-494-8573 (patient care)
503-494-4496 (fax)
toffler@ohsu.edu

Preventing Abuse and Exploitation: A Personal Shift in Focus. An article about guardianship, elder abuse and assisted suicide.

http://www.americanbar.org/publications/voice_of_experience/2014/winter/preventing_abuse_and_exploitationa_personal_shift_focus.html

http://choiceisanillusion.files.wordpress.com/2014/02/dore-preventing-abuse-and-exploitation-aba.pdf

By Margaret K. Dore, Esq., MBA

The Voice of Experience, American Bar Association

Volume 25, No. 4, Winter 2014

I graduated from law school in 1986.  I first worked for the courts and then for the United States Department of Justice.  After that, I worked for other lawyers, and then, in 1994, I officially started my own practice in Washington State.  Like many lawyers with a new practice, I signed up for court-appointed work in the guardianship/probate context.  This was mostly guardian ad litem work.  Once in awhile, I was appointed as an attorney for a proposed ward, termed an “alleged incapacitated person.”  In other states, a guardianship might be called a “conservatorship” or an “interdiction.”  A guardian ad litem might be called a “court visitor.”

My Guardianship Cases

Most of my guardianship cases were straightforward.  There would typically be a elderly person who could no longer handle his or her affairs.  I would be the guardian ad litem.  My job would be to determine whether the person needed a guardian, and if that were the case, to recommend a person or agency to fill that role.

My work also included private pay cases with moderate estates.  With these cases, I would sometimes see financial abuse and exploitation.  For example, there was an elderly woman whose nephew took her to the bank each week to obtain a large cash withdrawal.  She had dementia, but she could pass as “competent” to get the money.  In another case, “an old friend from 30 years ago” took “Jim,” a 90 year old man, to lunch.  The friend invited Jim to live with him in exchange for making the friend sole beneficiary of his will.  Jim agreed.  The will was executed and he went to live with the friend in a nearby town.  A guardianship was started and I was appointed guardian ad litem.  I drove to the friend’s house, which was dilapidated.  Jim did not seem to have his own room.  I asked him if he would like to go home.  He said “yes” and got in my car.  He was not incompetent, but he had allowed someone else to take advantage of him.  In another case, there was a disabled man whose caregiver had used his credit card to remodel her home.  He too was competent, but he had been unable to protect himself.

In those first few years, I loved my guardianship cases.  I had been close to my grandmother and enjoyed working with older people.  I met guardians and other people who genuinely wanted to help others.

But then I got a case involving a competent man who had been railroaded into guardianship.  The guardian, a company, refused to let him out.  The guardian also appeared to be churning the case, i.e., causing conflict and then billing for work to respond to the conflict and/or to cause more conflict.  I have an accounting background and also saw markers of embezzlement.  I tried to tell the court, but the supervising commissioner didn’t know much about accounting.  She allowed the guardian to hire its own CPA to investigate the situation, which predictably exonerated the guardian.  The guardian had many cases and if what I said had been proved true, there would have been political fallout.  There were also conflicts of interest among the lawyers.

At this point, the scales began to fall from my eyes.  My focus started to shift from working within the system to seeing how the system itself sometimes facilitates abuse.  This led me to write articles addressing some of the system’s flaws.  See e.g., Margaret K. Dore, Ten Reasons People Get Railroaded into Guardianship, 21 AM. J. FAM. L. 148 (2008), available at www.margaretdore.com/pdf/Dore_AJFL_Winter08.pdf; Margaret K. Dore, The Time is Now: Guardians Should be Licensed and Regulated Under the Executive Branch, Not the Courts, WASH. ST. B. ASS’N B. NEWS, Mar. 2007 at 27-9, available at http://maasdocuments.files.wordpress.com/2013/08/dore-the-time-is-now-ashx.pdf

The MetLife Studies 

In 2009, the MetLife Mature Market Institute released its landmark study on elder financial abuse. See https://www.giaging.org/documents/mmi-study-broken-trust-elders-family-finances.pdf  The estimated financial loss by victims in the United States was $2.6 billion per year.

The study also explained that perpetrators are often family members, some of whom feel themselves “entitled” to the elder’s assets.  The study states that perpetrators start out with small crimes, such as stealing jewelry and blank checks, before moving on to larger items or coercing elders to sign over the deeds to their homes, change their wills or liquidate their assets.

In 2011, Met Life released another study available at www.metlife.com/assets/cao/mmi/publications/studies/2011/mmi-elder-financial-abuse.pdf, which described how financial abuse can be catalyst for other types of abuse and which was illustrated by the following example.  “A woman barely came away with her life after her caretaker of four years stole money from her and pushed her wheelchair in front of a train.  After the incident the woman said, “We were so good of friends . . . I’m so hurt that I can’t stop crying.”

Failure to Report

A big reason that elder abuse and exploitation are prevalent is that victims do not report.  This failure to report can be for many reasons.  A mother being abused by her son might not want him to go to jail.  She might also be humiliated, ashamed or embarrassed about what’s happening.  She might be legitimately afraid that if she reveals the abuse, she will be put under guardianship.

The statistics that I’ve seen on unreported cases vary, from only 2 in 4 cases being reported, to one in 20 cases.  Elder abuse and exploitation are, regardless, a largely uncontrolled problem.

A New Development: Legalized Assisted Suicide

Another development relevant to abuse and exploitation is the ongoing push to legalize assisted suicide and euthanasia in the United States.  “Assisted suicide” means that someone provides the means and/or information for another person to commit suicide.  If the assisting person is a physician who prescribes a lethal dose, a more precise term is “physician-assisted suicide.”  “Euthanasia,” by contrast, is the direct administration of a lethal agent with the intent to cause another person’s death.

In the United States, physician-assisted suicide is legal in three states:  Oregon, Washington and Vermont.  Eligible patients are required to be “terminal,” which means having less than six months to live.  Such patients, however, are not necessarily dying.  One reason is because expectations of life expectancy can be wrong.  Treatment can also lead to recovery.  I have a friend who was talked out of using Oregon’s law in 2000.  Her doctor, who did not believe in assisted suicide, convinced her to be treated instead.  She is still alive today, 13 years later.

Oregon’s law was enacted by a ballot measure in 1997.  Washington’s law was passed by another measure in 2008 and went into effect in 2009.  Vermont’s law was enacted on May 20, 2013.  All three laws are a recipe for abuse.  Onw reason is that they allow someone else to talk for the patient during the lethal dose request process.  Moreover, once the lethal dose is issued by the pharmacy, there is no oversight over administration.  Even if the patient struggled, who would know? [See e.g., http://www.choiceillusion.org/2013/11/quick-facts-about-assisted-suicide_11.html]

Here in Washington State, we have already had informal proposals to expand our law to non-terminal people.  The first time I saw this was in a newspaper article in 2011.  More recently, there was a newspaper column suggesting euthanasia “if you couldn’t save enough money to see yourself through your old age,” which would be involuntary euthanasia.  Prior to our law being passed, I never heard anyone talk like this.

I have written multiple articles discussing problems with legalization, including Margaret K. Dore, "Death with Dignity”: What Do We Advise Our Clients?," King Co. B. ASS’N, B. BuLL., May 2009, available at  www.kcba.org/newsevents/barbulletin/BView.aspx?Month=05&Year=2009&AID=article5.htm; Margaret K. Dore, Aid in Dying: Not Legal in Idaho; Not About Choice, 52 THE ADVOCATE [the official publication of the Idaho State Bar] 9, 18-20 (Sept. 2013) available at www.margaretdore.com/pdf/Not_Legal_in_Idaho.pdf  

My Cases Involving the Oregon and Washington Assisted Suicide Laws

I have had two clients whose parents signed up for the lethal dose.  In the first case, one side of the family wanted the father to take the lethal dose, while the other did not.  He  spent the last months of his life caught in the middle and traumatized over whether or not he should kill himself.  My client, his adult daughter, was also traumatized.  The father did not take the lethal dose and died a natural death.

In the other case, it's not clear that administration of the lethal dose was voluntary.  A man who was present told my client that the father refused to take the lethal dose when it was  delivered (“You’re not killing me.  I’m going to bed”), but then took it the next night when he was high on alcohol.  The man who told this to my client later recanted.  My client did not want to pursue the matter further.

Conclusion

In my guardianship cases, people were financially abused and sometimes treated terribly, but nobody died and sometimes we were able to make their lives much better.  With legal assisted suicide, the abuse is final.  Don’t make Washinton’s mistake.

Margaret K. Dore (margaretdore@margaretdore.com) JD, MBA, is an attorney in private practice in Washington State where assisted suicide is legal.  She is a former Law Clerk to the Washington State Supreme Court and the Washington State Court of Appeals.  She worked for a year with the U.S. Department of Justice and is president of Choice is an Illusion, www.choiceillusion.org, a nonprofit corporation opposed to assisted suicide and euthanasia.