Medical Aid in Dying

The New Hampshire House of Representatives narrowly approved House Bill 1283 in a 179 to 176 vote last month. The bill, if approved by the Senate and signed by the governor, would establish a legal process for state residents to acquire lethal doses of medication to end their lives rather than continuing to suffer the ravages of a terminal condition. 

The controversial practice, often referred to as “Medical Aid in Dying” or “Physician-Assisted Suicide,” was first adopted by Oregon in 1997. It has since been adopted by nine additional states (California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Vermont, and Washington) and Washington D.C. 

Medical Aid Dying has become a national debate. Advocates arguing for freedom of choice and a right to determine when and how one faces death insist that sometimes hospice and palliative care are not enough to relieve suffering. 

Opposition to HB 1283 and the Medical Aid in Dying movement has arisen from various corners of the ideological spectrum. These include conservative religious groups with classic “right to life” arguments as well as disability advocates. The latter express concern for the potential abuse of the mentally ill, disabled and older adults. 

There are serious concerns on both sides which demand serious reflection.

It would be helpful for ethicists and policymakers to step back and reset our bearings by asking about the effectiveness of the practice. Do Medical Aid in Dying programs empower patients, giving them more autonomy? Are they abusive and dangerous for the moral ethos of society? 

Better data is needed to address these questions. Thus, it was ironic that on March 20th, a day before the New Hampshire House approved HB 1283, the Oregon Health Authority (OHA) released the 23rd edition of its report on the Oregon Death with Dignity Act (DWDA).

According to the report, 560 individuals received prescriptions from 167 physicians under the DWDA in 2023. As of January 26th of this year, the OHA documents that 367 individuals died following the ingestion of DWDA-prescribed medication. 

The first thing that stands out in the report is the significant number of patients who requested and received prescriptions but did not take them. According to the OHA, 4,274 people have received prescriptions since 1997, but only 2,847 have ingested the medication and subsequently died. That is a rate of 67%, which makes DWDA deaths only .8% of the state’s total mortality rate. 

In addition, there was not a significant number of doctors writing an excessive amount of prescriptions. Of the physicians who wrote DWDA prescriptions, only 77% provided prescriptions for one or two patients that met the criteria for receiving them. 

The vast majority of Oregon providers did not even participate in the program. 

In addition, the report revealed that the vast majority of DWDA patients had a diagnosis of cancer (66%), followed by neurological disease (11%) and heart disease (10%). 

Demographically, patients were predominately over 65 (82%) and white (94%). Almost half (45.9%) of patients were married, and 96.3% of patients informed their families of their decision to take the medication. Patients largely died at home (87.7%), with a vast majority having already been admitted to hospice. 

What is most telling is not the demographics, but the reasons patients gave for requesting the medication in the first place. Most (91.6%) shared concerns about the loss of autonomy. 

The inability to participate in activities that make life enjoyable and a fear of the loss of dignity were also reported by 88.3% and 63.8%, respectively. These three concerns have consistently been listed by patients who have requested DWDA prescriptions for over a decade. 

The OHA report provides a plethora of data confirming that the Oregon program is following the parameters that were set up in the DWDA. However, there is still cause for concern, specifically the continued increase in the number of cases. 

In 2023, physicians wrote 560 DWDA prescriptions, up from 121, almost a fivefold increase from 2013. This increase comes without a clear explanation. 

This is not a new program. So the numbers would be expected to have been leveled out by now. 

With regard to the debate about Medical Aid in Dying, the OHA gives policymakers some direction. 

First, the annual survey reveals that patients are most concerned about personal autonomy and not pain and symptom management, as one would expect. As the nation continues seeing the number of patients requesting prescriptions rise, healthcare officials must ask why autonomy is still the number one concern. 

What are we doing wrong? How can we address this better? 

Next, the OHA revealed that the Oregon program has not fallen into massive abuse as was predicted two decades ago. All the concerns of those opposed to the practice cannot be dismissed either, as there is no explanation as to why the numbers keep going up. 

Therefore, policymakers and ethicists need to reframe the debate away from a “right to autonomy vs. right to life” framework and focus on patients’ concerns and why the numbers keep rising. In short, we must focus on how we care for end-of-life patients.