H A S T I N G S C E N T E R R E P O R T 37May- June 1999

n a public document,1 an article in theNew England Journal of Medicine,2 aNational Press Club briefing, and visitsto various congressional offices, theOregon Health Division (OHD) has

argued that assisted suicide is being carried out safe-ly under the state’s Death with Dignity Act. Unfor-tunately, the report is marked by its failure to addressthe limits of the information it has available, over-reaching its data to draw unwarranted conclusions.Most striking, and least justified, is its contentionwithout substantiating patient data that patientswho were assisted in suicide were receiving adequateend-of-life care. In fact, we know nothing about thephysical, psychological, and existential needs of thepatients requesting assisted suicide. We know little ofthe capabilities of the physicians who are respondingto those requests. And we know nothing of the con-text in which these patients live and are cared for.

We opposed the legislation, but since it waspassed both advocates and opponents share a re-sponsibility to see to it that the law is administeredso as to best protect patients. If insufficient data isbeing obtained in a flawed monitoring process,everyone should be concerned.

Limited Data

The data OHD has collected is largely epidemi-ological: the assisted suicide cases were divided

between men and women, the median age of the

patients was sixty-nine, all the patients were white,all but two of them had cancer, and the patientswho chose assisted suicide were more likely to be di-vorced or never to have married. Physicians partici-pating in assisted suicide are not asked to provideOHD with significant medical information abouttheir patients. They are merely asked to check off alist on an OHD form indicating that such statutoryrequirements as a written request for a lethal dose ofmedication, a fifteen-day waiting period, and con-sultation with another physician have been met.Only one line is provided for both diagnosis andprognosis, although a diagnosis of terminal illnessand prognosis of death within six months are the es-sential requirements for assisted suicide in the state.The form does not inquire on what basis the physi-cian made the medical diagnosis—for example, re-view of x-rays, written material, pathology reports,or other information. Nor are physicians asked toreport on what basis they made the prognosis—what tables they have used, what experts they haveconsulted. The form does not even inquire as to thepatient’s reasons for requesting assisted suicide. Thedata do not make it possible to know what tran-spired in any particular case.

To supplement the meager information requiredby formal reporting, OHD asked physicians whoparticipated in assisted suicide to respond in person

Kathleen Foley and Herbert Hendin, “The Oregon Report: Don’tAsk, Don’t Tell,” Hastings Center Report 29, no. 3 (1999): 37-42.

The Oregon Health Division’s report on assisted suicide under the state’s new legislation

does not provide enough data to support its reassuring conclusions. Especially glaring is the lack of

data on the palliative care offered to patients who requested assisted suicide, on their financial

situation, and on their emotional state.

TThhee OOrreeggoonn RReeppoorrttDon’t Ask, Don’t Tell

by K AT H L E E N F O L E Y and H E R B E R T H E N D I N

I

or by phone to a questionnaire thatwas also given to physicians of a com-parison (control) group of patientswho died of similar illnesses withoutassisted suicide. OHD does not tellus who asked the questions, whattheir training was, and whether anyfollow-up questions were asked. Butthe questionnaire (published on theInternet)3 and the report show thatthis effort was also flawed. Missingmedical information was not askedfor or provided.

In the absence of medical data,how does OHD reach its conclusionthat patients received adequate end-of-life care? From the facts—derivedfrom the physician questionnaire—that the proportion of patients whohad advance directives and were en-rolled in hospice programs was com-parably high for both the case andcomparison groups, and that neitherworry about pain control nor finan-cial concerns drove patients’ requestsfor assisted suicide. But neither ad-vance directives nor enrollment in ahospice program provides proof ofcompetent assessment and treat-ment—the essential components ofadequate care—any more than doespatients’ apparent silence about pal-liative care or financial concerns.Such figures cannot substitute for di-rect knowledge of patients and theirillnesses. Although the physiciansquestioned reported that more pa-tients requesting assisted suicide wereconcerned with loss of autonomy orloss of control of body functions thanwere those in the control group,physicians were not asked how theseconcerns were expressed or addressed.Without such information it is notpossible to judge the adequacy of thecare these patients received.

Issues in Care

Paalllliiaattiivvee CCaarree. Under the Oregonlaw, when a terminally ill patient

requests assisted suicide, physiciansare required to point out that pallia-tive care and hospice care are feasiblealternatives. They are not required,

however, to be knowledgeable abouthow to relieve either physical or emo-tional suffering in terminally ill pa-tients. Without such knowledge, andwithout inquiry into why the patientrequested assisted suicide, the physi-cian cannot present feasible alterna-tives. Serious evaluation of the end-of-life care that such patients receivedwould have to be conducted byphysicians trained in palliative care,able and willing to inquire about thenature of the patient’s illness and con-cerns and what was done to addressthem. We do not know that those atOHD administering the question-naire had such training.

The report stresses the fact thatonly one of the fifteen patients ex-pressed concern about inadequatepain control at the end of life. The re-port’s authors believe this may reflectadvances in palliative care in Oregonand the fact that the state ranks highin the use of morphine for medicalpurposes. Yet fifteen of the forty-three control patients were worriedabout end-of-life pain control, sug-gesting the concern is frequentamong those who are terminally ill.But the figures themselves are sus-pect. They are based on physicians’responses long after the fact to thequestion whether patients volun-teered such concerns about pain. Thephysicians did not directly ask the pa-tients about their pain. The inade-quacy of relying on physicians’ per-ceptions of patients’ experiences haslong been documented, particularlywith regard to pain: in numerouspublished studies physicians underes-timated what patients were experi-encing.4 In surveys of barriers to ef-fective pain relief, patients reportedthat they did not want to use theirtime with their doctors to discusspain relief but rather to discuss theirtreatments.5 This is particularly apt tobe true of patients requesting assistedsuicide, who if successful in persuad-ing physicians to give them a lethalprescription would have no need tobe concerned about future pain. Astudy surveying cancer patients withpain or depression showed how dif-

ferences in their attitudes towardphysician-assisted suicide would af-fect their choice of physicians: Pa-tients with pain reported they wouldchange physicians if they knew theirphysician participated in physician-assisted suicide. Those with depres-sion were more likely to seek out suchphysicians.6

Surveys of family members of dy-ing patients can provide insight intothe adequacy of palliative care services.The OHD report fails to cite the re-cent Oregon Board of Medical Exam-iners (BME) survey of 475 survivingfamily members listed as informantsfrom a stratified sample of Oregondeath certificants for 1997; the surveyshowed a statewide trend of higherrates of moderate to severe pain re-ported by family members of patientsdying in acute care hospitals through-out Oregon.7 The BME viewed thetrend as a “worrisome” statistic thatsuggested inadequate palliative care.

No data are available in the Ore-gon report on the major symptionsother than pain that interfere withpatient quality of life and affect theirsense of autonomy and control.8

TThhee LLeetthhaall PPrreessccrriippttiioonn.. The re-port, however, does help settle onemedical debate that went on betweenadvocates and opponents prior to im-plementation of the law. Opponentsof legalizing assisted suicide in Ore-gon pointed out that because therewas no reliable information about thelethal dose of drugs for medically illpatients, physicians assisting suicidewould essentially be experimentingon patients. In Dutch studies 20 per-cent of patients given 9 grams of bar-biturates, considered a lethal dose,lived for more than three hours.9

Dutch doctors usually then inter-vened with a lethal injection, whichwould be illegal in Oregon. In anumber of reported cases in thiscountry, after swallowing presumedlethal doses of barbiturates patientsdid not die and families intervenedwith pillows or plastic bags.10 Advo-cacy groups denied the validity of theDutch findings and of such accountsalthough recommending the 9-gram

38 H A S T I N G S C E N T E R R E P O R T May- June 1999

barbiturate dose, which was given byOregon physicians to fourteen of thefifteen Oregon cases. OHD noteswithout comment that four of the fif-teen patients lived longer than threehours and one lived as long aseleven—figures that are consistentwith the Dutch experience.

EEccoonnoommiicc FFaaccttoorrss.. The pitfalls thatresult from OHD’s inadequate meth-odology are nowhere more apparentthan in its conclusion that economicfactors did not influence the choiceof assisted suicide. OHD informs usthat apprehensions that assisted sui-cide would be chosen by those “fear-ful of the financial consequences oftheir illness” were unjustified. Thismay or may not be true, but theOHD is not in a position to know.The Oregon law does not ask physi-cians to inquire about patients’ eco-nomic or social circumstances, nordoes OHD require physicians to re-port such information.

On the basis of the physicianquestionnaire OHD concludes, “Noneof the case patients or control pa-tients expressed concern to their phy-sicians about the financial impact oftheir illness. We found no significantdifference between the case patientsand the control patients with regardto insurance at the time of theirdeath” (p. 580).

The apparent lack of differencesbetween the case and control groupsis more likely to reflect the lack ofsensitivity of the model and the su-perficiality of the data collected. It isvery unusual for physicians to have aclear understanding of the financialissues facing their patients. Morecommonly they are unaware of pa-tients’ out-of-pocket expenses, or ofother family and personal considera-tions. Physicians have little time todiscuss these issues and patients havestrong needs (out of pride) not toprovide this information to clini-cians. A patient requesting assistedsuicide may also feel that the requestis less likely to be granted if the physi-cian feels that the patient is makingthe request because he or she cannotafford proper care. Yet certainly when

a patient requests assisted suicide onewould expect physicians to inquireabout the patient’s ability to affordadequate care, whether or not the pa-tient raises the question and eventhough the law does not suggest thatphysicians do so.

Even among the insured there iscompelling evidence to suggest thatthe cost of end-of-life care can con-tribute to financial hardship. In acomprehensive study of end-of-lifecare, more than half of the families in-volved in the care of a seriously illfamily member reported at least onesevere financial burden, ranging fromloss of family savings and loss of in-come to changes in future educationalplans or employment status.11 Highdeductibles, copayments or a coinsur-ance, and limits of coverage can allcontribute to high out-of-pocket ex-penditures. Medicare covers only 83percent of typical charges for lungcancer and 65 percent of typicalcharges for breast cancer; it does notreimburse for out-of-pocket drug ex-penses, which can be particularly bur-densome. And hospice provides onlylimited nursing care (four hours perday) unless the patient is imminentlydying.

PPssyycchhiiaattrriicc EEvvaalluuaattiioonn. Since Ore-gon is the first state to legalize suicideas a treatment for medical illness, itwould seem to have a special responsi-bility to protect the significant num-bers of patients who become suicidal-ly depressed in response to serious orterminal illness. We know that med-ical illness is an important factor in 70percent of all suicides over the age ofsixty.12 We know also that two-thirdsof all suicides and two-thirds of thoserequesting physician-assisted suicide

are suffering from depression. Amongpatients requesting assisted suicideresearchers have found depression tobe the only factor that significantlypredicts the wish for death.13

Although a psychiatric evaluationis the standard of care for suicidal

patients, the Oregon law does notrequire it in assisted suicide cases.Under the law, only if the physicianbelieves that the patient might be suf-fering from a psychiatric or psycho-logical disorder or from a depressioncausing impaired judgment must thephysician refer the patient to a li-censed psychiatrist or psychologist forcounseling. Yet studies have shownthat physicians are not reliably able todiagnose depression, let alone to de-termine whether the depression is im-pairing judgment.14 Passik noted in astudy of cancer patients with moder-ate to severe depression that only 13percent of clinicians identified de-pression in the patient population.15

With such facts in mind, a task forceorganized by the Oregon Health Sci-ences University to guide caregiversadvised physicians to refer all cases re-questing assisted suicide for psychi-atric evaluation even though they arenot legally required to do so.16

Does OHD monitor the processto see to it that depressed patients areadequately protected? Psychiatristswho have examined patients andfound them depressed, with “im-paired judgment,” are not even askedto file a report with OHD. Buried ina table but not discussed in the reportis the fact that only four of the fifteenpatients who requested assistance insuicide were referred for psychiatricor psychological evaluation. Since allfifteen cases went forward we must

H A S T I N G S C E N T E R R E P O R T 39May- June 1999

Without knowledge of how to relieve physical

or emotional suffering, and without inquiry into

why the patient requested assisted suicide, the

physician cannot present feasible alternatives.

conclude that in no case was depres-sion or any other mental illness con-sidered to be compromising the pa-tient’s judgment.

If OHD wished to monitor thepsychiatric evaluation, a trained psy-

chiatrist or psychologist should haveinterviewed both the prescribingphysicians and the psychiatrists whosaw the four patients who were evalu-ated. Questions such as those askedin a psychological autopsy would beasked: Were the reasons for request-ing assisted suicide explored? Howdid the physician evaluate them?What was the physician’s response?Was the patient depressed? Whatwere the symptoms? Was treatmentoffered? What was the patient’s re-sponse? What other risk factors forsuicide were present, such as a fami-ly history of depression and/or sui-cide, alcoholism, or any past suicideattempts? What was the patient’spast experience with the death ofthose close to him or her? Did thepatient—like most suicides and as-sisted suicides—express any ambiva-lence about suicide? If so how wasthis expressed and how was it dealtwith? Physicians inexperienced indealing with suicidal patients tendto take requests to die literally andconcretely, failing to hear this am-bivalence.

It would have been valuable tocompare interviews with physiciansof eight additional patients who re-quested but did not carry out assistedsuicide: six who died of their underly-ing illnesses without using lethal pre-scriptions given them and two whowere still alive on 1 January 1999.

This information was not obtained.Yet at least the first six are essentiallydropouts in the study, a group thatinvestigators normally wish to com-pare with their cases. Such patientsmight provide us with further in-

sights into the complicated aspects ofpatient requests.

OHD might well consider thatpsychiatric assessment is intendedunder the Oregon law to deal onlywith the limited issue of a patient’scapacity to make the decision for as-sisted suicide. But then at a mini-mum OHD would need to monitoron what basis clinicians referred pa-tients for psychiatric evaluation andwhether these decisions were appro-priate. The psychiatrists approvingthe assisted suicide would have to beinterviewed to learn how well theyknew the patient, whether the pa-tient was seen more than once, andon what basis they decided the pa-tient was competent. When surveyed,only 6 percent of Oregon psychia-trists were confident that absent along-term relationship with a patientthey could satisfactorily determinein a single visit whether that patientwas competent to commit suicide.17

The same survey revealed that themajority of those willing to evaluatea patient’s competence for assistedsuicide favor the practice, leading theinvestigators to conclude that “a biasmay be introduced into the compe-tency evaluation” (p. 1474). Whenadvocacy groups, like Compassionin Dying, are shepherding the casesand the referrals, the likelihood ofsuch bias would seem to be evengreater.

A Public Case

Although the Oregon report tellsus nothing about any individual

case, we do know a little about one ofthe fifteen patients who requestedand carried out assisted suicide. Thefirst case known to the public underthe new law was publicized by Com-passion in Dying, the advocacy groupshepherding many of the Oregon as-sisted suicides.

The patient was described as beingin her mid-80s with metastatic breastcancer and in a hospice program.18

The patient’s own physician had notbeen willing to assist in her suicidefor reasons that were not specified. Asecond physician also refused on thegrounds that she was depressed. Herhusband called Compassion in Dyingand was referred to a doctor willingto participate. The doctor referredthe patient to a second physician andto a psychiatrist who supported thedecision. Much of the informationabout the case came from an audio-tape the physician made of an inter-view he had with the patient. Anedited version of the audiotape wasplayed for the media by Compassionin Dying the day after the patient’sdeath.

On the tape, said to have beenmade two days before she died, thepatient says of her impending death“I’m looking forward to it. . . . I willbe relieved of all the stress I have.”

The patient expressed concernabout her autonomy, specificallyabout being artificially fed, a concernthat suggests some vulnerability anduncertainty about her course of ac-tion. The physician does not assureher that this need not happen in anycase. He ignores the remark and in-stead asks a question designed to elic-it a response about her desire to die.

PPaattiieenntt:: I’ve seen people suffer,they give them artificial feedingand stuff, which is really not doinganything for them in the long run.

DDooccttoorr:: Can you explain how youfeel about dying in a few days?

40 H A S T I N G S C E N T E R R E P O R T May- June 1999

The presumption that a diagnosis of terminal

illness is sufficient for assisted suicide does not

encourage physicians to inquire into the source of

the medical, psychological, social, and existential

concerns that usually underlie such a request.

There is no indication that thisphysician was trying to find any feasi-ble alternatives to suicide. In thetaped interview released to the publicthe physician follows the law’s re-quirement, simply listing other choic-es she could make: hospice support,chemotherapy, and hormonal therapy.

DDooccttoorr:: There is, of course, allsorts of hospice support that isavailable to you. There is, ofcourse, chemotherapy that is avail-able that may or may not have anyeffect, not in curing your cancer,but perhaps in lengthening yourlife to some extent. And there isalso available a hormone whichyou were offered before by theoncologist—tamoxifen—which isnot really chemotherapy but wouldhave some possibility of slowing orstopping the course of the diseasefor some period of time.

PPaattiieenntt:: Yes, I don’t want to takethat.

DDooccttoorr:: All right, OK, that’s pret-ty much what you need to under-stand.

The case raises disturbing ques-tions. The physicians who evaluatedthe patient offered two contradictorysets of opinions about the appropri-ateness of her decision. As the deci-sionmaking process progressed, itprovided no mechanism for resolvingthe disagreement based on medicalexpertise, such as that which can beprovided by an ethics committee thatwould hear the facts of the case beforegoing forward. Instead, the opinionsof the two doctors who did not sup-port the patient’s decision—one ofwhom knew her for some time andthe other who considered that she wasdepressed—are essentially ignored.

To evaluate fairly the adequacy ofthe end-of-life care provided this pa-tient OHD would need to interviewher first two physicians as well asthose who participated in the assistedsuicide. The report indicates that insix of the fifteen cases the first physi-cian seen by the patient did not agreeto assist in the suicide; none of these

physicians were contacted by OHD.And although the OHD reportedthat none of the cases in either thecase group or the control group ex-pressed financial concerns, a memberof this patient’s family told a reporterfor The Oregonian that the patientwas concerned that her financial re-sources not be dissipated by hercare.19

Protecting Patients at the End of Life

The flaws in OHD’s monitoringcome in part from the problems

and flaws in the Oregon law. Intoler-able and unrelievable suffering—arequirement for assisted suicide in theNetherlands—is not a requirement ofthe Oregon law; the diagnosis of aterminal illness is sufficient. The pre-sumption and stipulation in the Ore-gon law that a diagnosis of terminalillness is sufficient for assisted suicidedoes not encourage physicians to in-quire into the source of the medical,psychological, social, and existentialconcerns that usually underlie such arequest, an inquiry that leads patientsand physicians to have the kind ofdiscussion that often leads to relief forpatients and makes assisted suicideseem unnecessary. Nor are physiciansasked or required by the Oregon lawto make such an inquiry. Certainlysuch a discussion with the patient de-scribed above would have includedconsideration of her fears of beingartificially fed and assurance that shedid not need to choose assisted sui-cide in order for that not to happen.

Although the questionnaire givento physicians provides three lines forthem to reply to a question as to whytheir patients chose to request assistedsuicide, if the physicians had not pre-viously explored the matter with theirpatients those replies are of question-able value. That the Oregon HealthSciences University which examinedthe law felt it necessary to recom-mend that physicians ask patientswhy they are requesting assisted sui-cide suggests this weakness of the law,how unprepared Oregon physicians

are to deal with it, and how unpro-tected Oregon patients are by it.

OHD monitoring reflects the law’spredilections so that OHD seems de-termined not to ask the tough ques-tions and not to ask them of the rightpeople. Patients are not asked to com-plete and provide any information tothe state. Over 70 percent of the pa-tients were in hospice care but, sinceOHD did not interview hospice staff,hospice nurses and social workerswho may have the most knowledge ofthe patients were given no voice in themonitoring process. And the informa-tion physicians provide is far too lim-ited to be relevant to those wanting tounderstand the end-of-life care thesepatients receive.

The physicians who did not agreeto assist in suicide are not interviewedby the OHD and on the basis of doc-tor-patient confidentiality cannotspeak publicly about the reasons fortheir refusal. This is in contrast tophysician advocates, some of whomtalk and write publicly about thetreatment. One wonders if they havetheir patients’ permission to do so.

Fifteen cases in a year was seen as asmall number and as such interpretedas indicating that the law was notlikely to be abused. In such a contro-versial procedure, however, one mightexpect patients and physicians to beat first hesitant about participating.Although we do not have figures forthe early years in the Netherlandswhen assisted suicide and euthanasiawere first given legal sanction, theyappear to have been practiced at firstrelatively infrequently. It was onlyafter the practice became generallyaccepted for some years that thenumbers rose significantly. Some ofthe early Dutch patients were advo-cates of assisted suicide who usedtheir deaths partly to make a state-ment in behalf of a cause in whichthey believed. There has been somequestion as to whether the Oregonpatients might either be advocates ordisproportionately shepherded by ad-vocacy groups to chosen physicians.The physician questionnaire partlyaddressed this latter concern in ask-

H A S T I N G S C E N T E R R E P O R T 41May- June 1999

ing, “Was the patient specifically re-ferred to you regarding PAS by anorganization such as Compassion inDying or the Hemlock Society?”20

Inexplicably, OHD did not publishthe answer. We know, however, fromthe period when those organizationsthought it useful to publicize their in-volvement, that the first few patientswere referred through them to physi-cians who would prescribe lethalmedication.

After information about the firstcase had been made public, one ofthe authors of the OHD report toldThe Oregonian that too much infor-mation had been revealed. “They[the public] want to know [the law]worked in general and other thanthat they were almost embarrassed toread about the details.” She went onto say that it would seldom happenin the future.21 If what we knowabout the first assisted suicide is at alltrue of others, details about how thelaw is operating would probably bemore embarrassing to OHD than tothe public.

What is perhaps most disturbingin Oregon—and most similar to theNetherlands22—is that those admin-istering the law and those sanctionedby the government to analyze its op-eration have become its advocates.The overreaching conclusions in theOHD report and the public relationscampaign that accompanied its re-lease—from the National Press Clubbriefing to the visits to various con-gressional offices—seem to belie theclaim of its authors that they are sim-ply a “neutral party” collecting data.

OHD has a higher responsibility,to present what it knows and admitwhat it does not. The ideal solutionwould be for OHD to appoint a taskforce made up of physicians from outof the state who are experts in pallia-tive care, psychiatry, and medicine toreview the assisted suicide cases. Per-haps even to embark on a prospectivestudy. Unless physicians are asked toreport more than they are now re-

quired to under the law, and unlessproperly trained independent physi-cians can question the physicians andexamine the data, we will not learnmuch from the Oregon experience.Nor will we be assured that patientswho choose assisted suicide are receiv-ing appropriate care at the end of life.

References

1. “Oregon’s Death with Dignity Act:The First Year’s Experience,” Oregon De-partment of Human Resources, 18 Febru-ary 1999.

2. Arthur Eugene Chin, Katrina Hed-berg, Grant K. Higginson, and David W.Fleming, “Legalized Physician-Assisted Sui-cide in Oregon—The First Year’s Experi-ence,” New England Journal of Medicine340 (1999): 577-83.

3. Oregon Death with Dignity Act, Pre-scribing Physicans Interview Form. WorldWide Web at www.ohd.hr.state.or.us/cdpe/chs/pas/pas.htm.

4. Stuart A. Grossman, Vivian R. Shei-dler, Karen Swedeen et al., “Correlation ofPatient and Caregiver Ratings of CancerPain,” Journal of Pain and Symptom Man-agement 6 (1991): 53-57.

5. Sandra E. Ward, Nancy Goldberg,Vivian Miller-McCauley et al., “Patient Re-lated Barriers to Management of CancerPain,” Journal of Pain 52 (1993): 319-24.

6. Ezekiel J. Emanuel, Diane L. Fair-clough, Elisabeth R. Daniels, and Brian R.Clarridge, “Euthanasia and Physician-Assisted Suicide—Attitudes and Experi-ences of Oncology Patients, Oncologists,and the Public,” The Lancet 347(1996):1805.

7. Susan Tolle and Kathleen Haley, “PainManagement in the Dying . . . Successesand Concerns,” Oregon BME Newsletter,Fall 1998.

8. Russell K. Portenoy, Howard T. Thaler,Alice B. Kornblith et al. “The MemorialSymptom Assessment Scale,” European Jour-nal of Cancer 30A (1994): 1326-36.

9. Gerrit Kimsma, “Euthanasia and Eu-thanizing Drugs in the Netherlands,” inDrug Use in Assisted Suicide and Euthanasia,ed. Margaret P. Battin and Arthur G. Lip-man (Binghamton, N.Y.: Haworth Press,1996), p. 200.

10. Timothy E. Quill, A Midwife throughthe Dying Process: Stories of Healing andHard Choices at the End of Life (Baltimore:Johns Hopkins University Press, 1996);George E. Delury, But What If She Wants to

Die? A Husband’s Diary (Secaucus, N.J.:Birch Lane Press, 1997); Ann Wickett,Double Exit: When Aging Couples CommitSuicide Together (Eugene, Ore.: HemlockSociety, 1989).

11. Kenneth E. Kovinsky, C. Seth Lan-defeld, Joan Teno et al., “Is EconomicHardship on the Families of the Seriously IllAssociated with Patient and Surrogate CarePreferences?” See also SUPPORT Investiga-tors, Archives of Internal Medicine 156(1996): 1737-41.

12. Thomas B. MacKenzie and MichaelK. Popkin, “Medical Illness and Suicide,” inSuicide over the Life Cycle, ed. Susan J. Blu-menthal and David J. Kupfer (Washington,D.C.: American Psychiatric Press, 1990), p.308.

13. Emanuel et al., “Euthanasia andPhysician-Assisted Suicide”; Harvey M.Chochinov, Keith Wilson, Murray Enns etal., “Depression, Hopelessness, and Suici-dal Ideation in the Terminally Ill,” Ameri-can Journal of Psychiatry 152 (1995): 1105-91.

14. George E. Murphy, “The Physician’sResponsibility for Suicide: (1) An Error ofCommission and (2) Errors of Omission,”Annals of Internal Medicine 301 (1975): 82.

15. Steven D. Passik, Margaret V.McDonald, William Dugan et al., “Oncol-ogists Recognition of Depression in TheirPatients with Cancer,” Journal of ClinicalOncology 16 (1998): 1594-1600.

16. Kathleen Haley and Melinda Lee,eds., The Oregon Death with Dignity Act: AGuidebook for Health Care Providers (Port-land, Ore.: Task Force to Improve Care ofTerminally-Ill Oregonians, 1998), p. 67.

17. Linda Ganzini, Darien S. Fenn,Melinda A. Lee et al., “Attitudes of OregonPsychiatrists toward Physician-Assisted Sui-cide,” American Journal of Psychiatry 153(1996): 1469-75.

18. Herbert Hendin, Kathleen Foley,Margot White, “Physician-Assisted Suicide:Reflections on Oregon’s First Case,” Issuesin Law and Medicine 14 (1998): 243-70.

19. Erin Hoover Barnett, “Dealing withan Assisted Death in the Family,” The Ore-gonian, 21 February 1999.

20. Oregon Death with Dignity Act.www.ohd.hr.state.or.us/cdpe/chs/pas/pas.htm, Question 35.

21. Erin Hoover Barnett, “Third KnownAssisted Suicide Reported,” The Oregonian,6 May 1998.

22. Herbert Hendin, Seduced by Death:Doctors, Patients, and Assisted Suicide (NewYork: W. W. Norton, 1998).

42 H A S T I N G S C E N T E R R E P O R T May- June 1999