WASHINGTON SEES THE LIGHT

Washington state, that is, not Washington, D.C. Our Death With Dignity allies up there deserve big congratulations and heartfelt thanks for their doggedly skillful efforts in passing I-1000 by a 58% to 42% margin on November 4. As a result, their state now joins Oregon in permitting physician assistance to terminally ill patients who wish to end their lives.
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Former Washington Governor Booth Gardner, himself a sufferer of Parkinson’s Disease, played a defining role in achieving this victory, both with his cogent arguments and his political know- ledge. Despite, we should note, determined, well financed oppo- sition from religious conservatives spearheaded by elements of the Catholic Church. Hats off to Mr. Gardner and his whole team.
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As for that other Washington, our nation’s capital, I’m afraid we'll have to wait before the light of sensible DWD policy shines there. President-elect Obama has a very full agenda, though perhaps we dare hope that somewhere along the line he might guide the changes in attitudes and law necessary to recognize that the freedom to choose DWD is a right all should have.

POSTER CHILDREN?

In a previous blog (Life and Death in the Great Northwest – Part I) I wrote about Oregon’s successful Death With Dignity law and the upcoming election in Washington state where something nearly identical is on the ballot. I also mentioned political opposition to the Washington measure in the form of millions of dollars from religious conservatives, particularly the Catholic Church. Even the Portland Archdiocese has contributed a hefty sum, notwith- standing its struggle to pay for past child sexual abuse cases.

Now Fox News and the right-wing blogosphere have chimed in big as well. Since this is a campaign, and every campaign needs a poster, the search seems to be on for poster children. The leading candidate at the moment may be Randy Stroup, 53 years old, from Dexter, Oregon, who is afflicted with a recurrent prostate cancer judged to be terminal. A second Oregonian, 64 year-old Barbara Wagner, terminally ill with recurrent lung cancer, has made news as well, though not at the national level.

Without actually interviewing Mr. Stroup or Ms. Wagner, I’ve done my best to learn the facts. But first, we should express sympathy for them and acknowledge the cruel situations they face. Both, as noted, are terminally ill, with Stroup still a rela- tively young man, and both receive their health care through a public Oregon program coordinated with Medicaid, because neither could afford care otherwise. They both have received the full range of standard treatments, but both are now on the wrong side of Oregon’s long-standing and perfectly legal "5 in 5 rule"—no treatments exist that offer a 5% or greater chance of ensuring their survival for 5 or more years.

In both cases there are expensive new chemotherapy agents that might postpone their deaths by two to six months, with some possible gain in quality of life, but the costs are beyond what Oregon’s plan will pay. When the "5 in 5 rule" can’t be met, it covers only hospice care, palliative care—i.e. intervention for comfort and pain reduction—or access to lethal drugs under the state’s Death With Dignity law. Both Stroup and Wagner have received coverage denials in writing, yet the letters were so inartfully written that a nudging by the state toward the last of those options could be inferred. It was this that Fox News, et al seized upon to allege that Oregon is headed down the slippery slope to forced euthanasia, just as Death With Dignity opponents had predicted all along. Sadly, Stroup may believe that himself.

Maybe he’s at least enjoying the attention, and I don’t begrudge him, nor do I know how he got on Fox News’s radar, but the timing of the blowup in view of the election in nearby Washington hardly seems coincidental. Meanwhile, Ms. Wagner has actually benefited. Sensing a PR coup, Big Pharma, in this instance Genentech, has gifted her a one-year supply of erlotinib, the $4,000-per-month pills in question. All to the good, of course, so let’s hope the treatment works spectacularly and she beats the odds. Stroup hasn’t yet been as lucky, and it would be great if something broke in his favor too.

But what about the underlying argument. Is Oregon forcing people into euthanasia? No, not even close, though were that true, it would certainly be worth getting excited about. The fact is, Stroup and Wagner, by any measure, are better off under the health plan they have than with nothing, and in my opinion, better off in Oregon than they would be elsewhere.

Without health coverage, as President Bush said in discussing the uninsured, "you can always go to the ER." But does anyone ima-gine an ER would provide and pay for these kinds of treatments? Or would Medicaid in some other state? Slim chance. Or if Stroup and Wagner had private insurance, would their coverage extend that far? Not in 99% of the policies out there. So medically, in terms of what’s available to them at affordable cost, the Oregon Health Plan is it. And Oregon is also better, because the usual options of hospice or palliative care are delivered in a manner found by a recent University of Wisconsin study to rank Oregon with three other states as best in the nation. Moreover, uniquely in Oregon, patients can decide if and when to end their own suffering in the future should they choose.

Fox News was aflame with the horrors of medical rationing and the sinister presence of euthanasia. As if we don’t have rampant medical rationing now throughout the US that goes all but un- remarked. Under our so-called health care system, you get the treatment you can pay for, or some bedrock minimum, varying state-by-state, through public assistance when you’re out of money. For anything beyond that, tough luck. A better designed, more efficient and more universal system would undoubtedly raise the level of that bedrock minimum in many places, which I wholeheartedly support, but no system, public or private, would or could meet every imaginable need for every patient.

That happens only when you’re the one writing the checks, after which you still may die, sometimes in even greater pain, on the schedule originally forecast. In cancer we’re fighting a not fully understood disease with remedies that are at best only approxi- mately equal to the job. That’s why Stroup and Wagner had re- currences.

As a result, Genentech, not Oregon taxpayers, ought to be footing the bill for Ms. Wagner’s treatment. She’s in a fashion serving as their guinea pig, and if their brand of erlotinib proves more ef- fective than previous clinical trials have demonstrated, they’ll be handsomely rewarded with future profits. Fox News and other political opponents of Washington State’s Death With Dignity initiative seem bent on working up outrage over Stroup and Wagner, but sorry, I don’t see it. All I see is that the wording of Oregon’s treatment denial letters badly needs to be revised.

LIFE AND DEATH IN THE GREAT NORTHWEST - PART I

Since Oregon has always been a socially pioneering sort of place, we can’t be surprised that the Portland metro area is the nation’s most successful example of containing sprawl by setting and sticking to an urban growth boundary. Or that, in an effort to boost turnout and reduce costs, Oregon is unique among the fifty states in holding all statewide elections entirely by mail-in ballot.

More notoriously, of course, Oregon is also unique in having passed, and after many subsequent challenges, having retained on its books for over ten years now a straightforward Death With Dignity law. As ultimately upheld by the US Supreme Court, terminally ill Oregonians, subject to specific conditions and safeguards, have the right to physician assistance in dying. Once those conditions and safeguards are met, the assistance takes the form of a physician prescribing a lethal dose of an approved drug, which the patient then ingests, or not, at a time and place of their own choosing, according to the directions provided. The physi- cian is not expected to be in attendance, nor are physicians re- quired to offer this assistance if they have a moral objection.

After a decade of experience, fewer than 350 persons (1/10 of 1% of all Oregon deaths) have availed themselves of that option, although another 200 have received the prescribed drug and chosen, for whatever reason, not to proceed. Forty individual physicians have participated. No coercion toward a hastened death from family members or the government is permitted, and to my knowledge there have been no documented cases of abuse. What is known, however, is that terminally ill patients who have gotten the drug, whether they use it or not, report a having a greater sense of control over their destiny and feeling more peace of mind in facing the continued deterioration of their health.

This is old news, you say, so why do I belabor it? Two reasons. First, the November 2008 election in Washington, Oregon’s neighbor to the north, will put before voters an initiative statute, I-1000, closely modeled on the Oregon law. If current polls can be believed, it will pass, and the campaign in favor is being led by a popular former governor, Booth Gardner, who is visibly af- flicted with Parkinson’s Disease. Besides, Washington, though not as socially pioneering as Oregon, is itself a fairly independent-minded place.

There is opposition, as one would expect. As in Oregon, religious conservatives, especially the Catholic Church, can’t find enough ways to condemn the idea. Virtually all religions seek control over the births, marriages and deaths of their parishioners, the reasons for which are obvious. And since church affiliation in the US is freely chosen, no harm done. It's a voluntary compact. Whether government should intrude itself to insist that death occur in a way that ignores the wishes of the dying person and ignores the contributions modern medicine can make to that event is another question. Where, for instance, is the compelling state interest? I am fascinated to see what the Washington voters have to say about it. Church groups, meanwhile, are pumping millions into ads urging No on I-1000.

But perhaps the most interesting new development along these lines is occurring in Montana, a famously libertarian state that is separated from Washington to the east by only a thin neck of Idaho. We’ll discuss both Idaho and Montana in my next post.