A retrospective study over the last 25 years of the practice of medical assistance in dying in Oregon (United States) shows the constant rise in the number of cases over the last 25 years and an extensive interpretation of its application criteria.
Oregon was the first American State, in 1997 to pass a law authorising medical assistance in dying known as the “Death with Dignity act”. British scientists have analysed the evolutions in the legislation which is often presented as a “model” by studying the data in the annual reports issued between 1998 and 2022 by the Oregon Health Authority (OHA). Their analysis, published in October 2023 by BMJ Support Palliative care shows the abuse of the system through several factors: the number of people resorting to medical assistance in dying, the eligibility criteria, the socio-demographic characteristics, the reasons for resorting to medical assistance in dying and the information concerning the procedures for the act.
The term medical assistance in dying (MAID) refers to “the self-administration of a lethal product”. The law in Oregon specifies that the prescription for the product must be provided by a doctor but that the latter’s presence at the moment of administration is optional. The person requesting MAID must be an adult, capable of taking and expressing medical decisions, and must have been diagnosed with a terminal phase disease with less than six months life expectancy. A 15-day cooling-off period is required before being able to conduct the MAID act.
Evolution of the “medical” practice
Over the last 25 years, 2,454 people have died through MAID, increasing from 16 in 1998 to 278 in 2022. That represents 0.6% of all deaths. In comparison to the population in France, that would equate to some 4,000 MAID acts per year. The average age of MAID patients is 72.5 years.
The data for 2022 provided in the latest annual report reveal that 431 prescriptions were issued by 146 doctors. The prescribing doctors represent 0.9 % of the total number of doctors in Oregon which indicates a concentration of this practice on a minority of doctors. Most of those doctors prescribe the act once or twice per year, apart from one doctor who prescribed 51, which corresponds to virtually one per week.
All the people having been provided with a prescription for MAID do not necessarily use it. However, there is a lack of data concerning the reasons for such non use: either the patients died from their disease, or they abandoned the idea of MAID. No information is provided on the products procured and not used. The proportion of deaths following the self-administration of the prescribed lethal product compared with the number of prescriptions has increased from 58% during the first ten years following legalisation to 67% over the last 5 years.
Over 25 years, a strong reduction was noted of the duration of the therapeutic relationship with the prescribing doctor. It has fallen from 18 weeks in 2010 to a mere 5 weeks in 2022. The psychiatric evaluations to verify the applicant’s ability to take such a decision have practically disappeared. From 28% during the first 3 years following legalisation, the figure has fallen to a mere 1% of those resorting to MAID in 2022. The authors are concerned about the possible influence of this reduction in psychological evaluations and the reduction of the therapeutic relationship on the diagnosis of treatable factors such as solitude, depression and anxiety influencing the request to die.
Although the figures indicate ready availability of palliative care (an average of 90.8% between 1998 and 2020), there is no information concerning what exactly this availability represents. The term “palliative care” refers to the provision of comforting care when no other treatments are covered by social security. It is not specified whether this includes multi-disciplinary care or that provided by a single non-specialist practitioner. This lack of information fails to identify whether the patients received adequate palliative care before resorting to MAID.
Finally, in recent years the lethal products used have evolved. Although a lack of data on dosages prevents any precise analysis, the feedback in the 2022 report appears to suggest that the products used could have a tendency to increase the time elapsed between the self-administration of the product and the ensuing death. According to the 2022 report, of the 165 patients for whom this indication is known, the time lapse varied from 3 minutes to 68 hours with an average value of 52 minutes.
The evolution in the eligibility criteria and processes is quite puzzling
The scientists point out the non-compliance with the criteria stipulated by the law. Such as for example the 15-day cooling-off period which a quarter of the patients were exempted from in 2022 due to the imminent terminal phase of their illness. Although the requests concerned cancer patients in 80% of cases during the first five years, they represented only 64% in 2022. Since 2010, some patients have been resorting to MAID due to multiple non-terminal pathologies (such as arthritis, complications following a fall, a hernia, sclerosis or mental anorexia) which do not correspond to the diagnosis of an illness leading to death within 6 months.
The reasons given by patients when asking to die vary from a fear of losing their autonomy to financial difficulties.
90% of them mention a loss of autonomy, as well as the loss of the ability to take part in the activities which make life enjoyable, 74% mention a loss of dignity and 27% the lack or a fear of the lack of pain relief. The feeling of being a burden on their entourage has increased from 30% during the first five years following legalisation to 46% in 2022.
Finally, financial considerations are on the increase. Concern on the cost of treatments sometimes leading to rejecting treatments and applying for MAID reached 8.1% in 2021. The authors also observed an evolution in the social categories of patients since 2008 based on medical insurance which is a life-style indicator in the United States. An average of 65% of MAID applicants had private medical insurance up till 2008. The trend then completely reversed: 79.5% of patients requesting MAID subscribe to public medical insurance including Medicaid which is granted to those living below the threshold of poverty. These indications merit a more detailed study insofar as the Medicaid proportion in the public insurance category could not be determined.
The authors of the study concluded that the data remain limited and that the doctors are present in a mere 25% of cases at the moment of swallowing the lethal product and in 28 % of cases in 2022, the patients are alone. More detailed studies are obviously needed.
Currently 10 out of 50 States in the US have adopted legislation authorising MAID: in addition to Oregon, they are the states of Washington, California, Colorado, New Mexico, Maine, Vermont, New Jersey, District of Columbia (Washington DC), and Hawaii. The State of Montana tolerates it as a result of precedent. The American Medical Association (AMA) reaffirmed its opposition to MAID on 14th November following renewed pressures to adopt a more neutral position.
