The Roman Catholic Church called it a sin. The American Medical Association described it as unethical. C. Everett Koop, the former Surgeon General, said it was dangerous to society’s health. But Oregonians, enhancing their reputations as Western mavericks, have apparently ignored the advice of outsiders and made their state the first jurisdiction in the world to legalize doctor-assisted suicide. - The Oregonian , November 10, 1994
Election day in Oregon brought the unprecedented acceptance of physician-assisted suicide by voters. This event may represent only an anomalous electoral outcome, the result of the special social character and ethical climate of a single state in the American West. But it might also define a critical moment in our culture, a turning point in the nation’s understanding of medicine, personal autonomy, and death. My purpose here is not to address the issue substantively, but to reflect on why the interdenominational campaign against physician-assisted suicide failed in Oregon and to consider the future.
The measure itself, number sixteen in a crowded field of ballot initiatives, read:
Question: Shall law allow terminally ill adult patients voluntary informed choice to obtain physician’s prescription for drugs to end life? Summary: Adopts law. Allows terminally ill adult Oregon residents voluntary informed choice to obtain physician’s prescription for drugs to end life. Removes criminal penalties for qualifying physician-assisted suicide. Applies when physicians predict patient’s death within 6 months. Requires: 15-day waiting period; 2 oral, 1 written request; Second physician’s opinion; Counseling if either physician believes patient has mental disorder, impaired judgment from depression. Person has choice whether to notify next of kin. Health care providers immune from civil, criminal liability for good faith compliance. Estimate of Financial Impact: No financial effect on state or local government expenditures or revenue.
Having learned from its earlier, failed attempts in California and Washington, the Hemlock Society, the national leader of the "right-to- die" movement, devised a measure phrased in the language of safeguards, permission, and personal choice. It avoided active physician involvement by selecting suicide pills as the means of death rather than injections. A waiting period, multiple patient requests, a second physician opinion, and certification of mental soundness were all included to reassure voters of the measure’s deliberation. Readers should notice the extent to which family members are kept at a distance. Besides a privacy clause, allowing the patient to avoid disclosure of intention, the provisions of the act require that there be one witness to the patient’s written request who is neither a relative nor a potential beneficiary. These stipulations were especially important in framing the public debate in Oregon, since voters on previous measures in nearby states had shied at the specter of physicians wielding hypodermic needles at the behest of relations and heirs. But this time in Oregon, the home state of the Hemlock Society, physician-assisted suicide was presented as a matter of personal autonomy, an act of Socratic dignity, the gentle embrace of death.
Opponents of the measure were cast as religious bigots. The "Coalition for Compassionate Care," the umbrella group that fought the measure, was initially organized and funded primarily by Roman Catholics. This was a great stroke of luck for proponents. They were able to introduce their measure as a secular and rational initiative directed against religious coercion. Citizens were invited to take back control of their lives. In its advertising, the campaign informed voters that "there are some people who think they have the divine right to control other people’s lives." Oregonians needed little tutoring in discerning who such medieval theocrats were.
Several other facts must be supplied to explain why this strategy succeeded. Besides an aura of rationality, the Hemlock Society had demographics and local culture in its favor. Oregon is one of the "least-churched" states in the nation. About a third of the population is classified as religiously affiliated; only Nevada, where gambling and prostitution are legal, is lower. Roman Catholics make up the largest denomination, but are only 10 percent of the population. The other major groups are the Mormons and evangelical Protestants. Moreover, Oregon has a long-standing tradition of anti-Catholicism, harking back to strong Ku Klux Klan activities earlier in the century, as well as pre-World War II efforts to prevent religious (especially Catholic) schools from operating, a movement that failed only on appeal to the Supreme Court. Within the last few years, anti-papal billboards, with a caricature of John Paul II as the Antichrist, were to be seen at prominent intersections in Portland and in other Northwest locations. The Hemlock Society was thus able to depict itself as a proponent of rational choice, while simultaneously exploiting prejudice against the religious minority in general and Catholics in particular.
Identification of opposition to the measure with Catholicism might have been avoided if other religious groups had been perceived in the public’s mind as early and strong opponents. Many were, but their opposition was not well known. While the major interdenominational group, Ecumenical Ministries of Oregon, did join the Roman Catholic Church in placing its own opposition statement in the official state voter pamphlet, no member denominations did so. About six weeks before the election, Ecumenical Ministries began to campaign actively and to demonstrate that denominational opposition was widespread. Indeed, the religious coalition finally included most Christian denominations, many orthodox and conservative Jewish congregations, as well as several Muslim, Buddhist, and Hindu groups. While efforts to mobilize opinion may well have been effective within these denominations themselves, the tardy coalescence of a unified front allowed proponents to marginalize religious opposition. In a state so "unchurched" and secular, this organizational failure proved costly.
The role of evangelical Protestants bears mentioning. The nascent alliance of traditional Catholics and evangelicals never developed publicly in Oregon. This was partly a function of limited organization among evangelical churches. However, as one long-time evangelical leader told me, his community has also felt the continuing effects of cultural and social "intimidation" by the largely liberal and secular Oregon establishment. The recent national media assault on the "religious right" has been a prevailing fixture in Oregon for several years now, particularly in the populous region between Portland and Eugene. And a tacit connection with the "gay rights" debate should also be noted. Oregon has been a major battleground for this issue: a ballot measure sharply restricting homosexual rights lost heavily in 1992; a scaled- down version was defeated by several percentage points in this election. Evangelicals, though not the originators of these measures, have been suspected as being sympathetic, and as a result have come under relentless attack in the mainstream media under the "religious right" rubric. This has led to political caution among Oregon’s evangelicals. In the case of the doctor-assisted suicide measure, it produced a slow public reaction within that religious community.
Another factor in the victory for "the right to die" was a striking inability of the opposition, both religious and secular, to secure high- profile support within the cultural and political mainstream, despite strenuous efforts to do so. It is interesting to note the groups formally in support of the measure, and perhaps more important, those that were officially neutral. The political left, as expected, turned out in force: the Democratic Party and the ACLU were in favor. Although the national American Medical Association opposes physician assistance in suicide, the Oregon Medical Association remained neutral, along with the Oregon Hospice Association and the Oregon Pharmacists Association. These local defections from what had been expected to be a united front by the medical mainstream within the state were especially damaging.
A final factor bears mentioning. It is always difficult to characterize clearly the political and cultural character of any state. Nevertheless, it seems fair to say that Oregon has a strong, if inchoate, libertarian streak. Church affiliation and libertarianism seem to be inversely proportional in America. Thus the "right to die" campaign was able to represent the issue as a general referendum "on getting government out of this important personal decision," and "on returning control of end of life decisions to where it belongs-with the dying person." Against this libertarian backdrop the measure’s proponents could offer genuine and moving testimonials from those whose loved ones had been forced by "the state" to die in protracted agony against their wishes and convictions. This strategy was aided, in highly personal terms, by the outgoing Democratic Governor, Barbara Roberts (whose husband died during her term of office) and by the widow of former Republican Governor Tom McCall (a totemic figure for many Oregonians). Opponents were thus faced with two tasks: to raise the level of debate to a plane of ethics beyond the emotive and the anecdotal, and then to argue against the regnant libertarian ethos. Communitarian ethics comes hard to Oregonians, especially to the rootless souls of the metropolitan areas who share in the Western propensity for frequent moves and scattered, broken families. While the sparsely populated rural counties generally opposed the measure, the more populated counties favored it. In the end it passed narrowly, 51 percent to 49 percent.
As the opening quotation from the Oregonian indicates, citizens of the suicide state are now reflecting on their status as "Western mavericks." A prominent Oregon historian averred, "Oregonians have a strong streak of individualism. It’s been an element in Oregon character since pioneer days." Similarly, the head of the Oregon Historical Society was quoted as saying, "The fact that there has been no dominant religion has allowed a moral flexibility that a lot of states don’t have." He went on to note, "This measure is in keeping with Oregon. Throughout history Oregon seems to be out there ahead of other states in testing things." The bottle bill, another national first, has been mentioned. Already the debate over public funding of physician-assisted suicide for those receiving state-supported medical care has begun.
Strangely enough, all sides are now pointing to the religiously anomalous character of Oregon, and to its consequent "moral flexibility." While this may describe Oregon accurately, there are some grounds for doubting that the state will remain unique. It is doubtless true that the sea of faith never had a high tide along the upper Pacific coast, but the melancholy roar of its receding tide-to use Matthew Arnold’s image-has been heard in many other states. Perhaps Oregon will prove to be unusual only because it has had no cultural need to discard a religious heritage. Wherever the tide falls low enough elsewhere, the ethics of the autonomous self may surface and prevail.
That is too large a question to pursue here. But several final, political observations are in order. As this account indicates, there is a critical need for building an interdenominational coalition on this question both at the local and national level. Despite the laudable efforts of Archbishop William Levada, Catholics were left out in the lead too long in Oregon, with disastrous results. Early and highly public interreligious coalitions will be necessary in most states. There is reason to believe that these can be formed. The "right to die" has limited support in the ethics of the Western religious traditions. And the issue has not yet become a political litmus test, requiring leaders to revise their tradition’s ethics in order to remain in coalition with their allies on the political and cultural left. Unlike abortion, there is no gender-political dimension to be overcome. Denominational leaders should make a concerted effort to press the ethical dimension of the issue, both within their religious communities and in the mainstream culture. A panorthodox coalition encompassing traditional Jews, Christians, and Muslims would be a potent force, difficult to dismiss as merely "the religious right." The ethical case has a fair chance of being seriously heard in most states.
This raises the difficult issue of the broader political ramifications of physician-assisted suicide. Here there is no certain line of demarcation. The Democrats, as the "pro-choice" party, can be expected to favor the practice nationally as they did here in Oregon. One goal for religious opponents of physician-assisted suicide is to keep the Democratic party at all levels neutral. If enough members of what remains of the New Deal coalition, especially Catholics and church- affiliated African Americans, make their ethical views known, there is some chance that neutrality might result. But that is unlikely for a reason as yet politically obscured, although it has emerged on the edge of the Oregon debate and will soon become central in the national discussion: the importance of physician-assisted suicide to homosexuals. The venereal plague of AIDS has made terminal illness a hideous fixture of life among gays. For this understandable and deeply felt reason, there appears to be overwhelming support for "death with dignity" among homosexuals. Because of their increased importance to the diminished Democratic party, homosexuals will put strong pressure on the national party and on liberal religious denominations.
The Republican Party, while nominally "pro-life," may not prove as reliable on this issue as it has been on abortion. It is well to remember that the GOP is a "qualified pro-life" party: anti-abortion but pro-capital punishment. The latter is particularly significant, since arguments regarding divine sovereignty and the taking of life may prove awkward for many Republicans. Although formally distinct, capital punishment and physician-assisted suicide are closely related in their ethical contours. Unlike abortion, both turn on the legal conditions under which the life of an adult citizen may be terminated. Admittedly, political dynamics may have more significance than ethical argumentation, but even here there is reason for concern. There is a long-standing libertarian tradition throughout the Republican Party in the mountain West, similar to that found in Oregon, and this region’s attitude could well coalesce with the party’s emergent Eastern wing. The latter, the faction represented by Governors William Weld of Massachusetts and Christine Todd Whitman of New Jersey, is socially libertarian, pro-choice, and fiscally conservative. They might very well choose to make support for doctor-assisted suicide a defining social issue. While it is unlikely that this faction could prevail in that struggle, Republican neutrality on the national level cannot be ruled out. Once again, a panorthodox coalition is needed to press the case.
A further point follows for the pro-life cause within the Republican Party. As readers of these pages are well aware, the GOP is under pressure to ease its platform plank favoring a constitutional amendment banning most abortions. The pressure has come not just from libertarians, but also from some pro-life supporters who seek limitations on abortion as first steps toward its elimination. Those who favor this course might consider forging some political link between the two issues. Modifications in the anti-abortion platform might be conceded in exchange for opposition to physician-assisted suicide. This is a bargain that the GOP’s libertarians might accept, softening the party’s language on the more exigent abortion issue while fixing its stance on an issue as yet politically under-defined.
This leaves the question of political venue: where should this political battle be carried out? Piecemeal in the states, or at the federal level? And what about possible legal strategies? Implementation of Measure 16 is at present on hold, pending an appeal in the federal courts. While this route might prove successful in banning the practice, it might also allow the solonic judiciary to discover in the Constitution a right to "death with dignity." There will need to be some immediate strategic reflection within the pro-life movement on these questions, along with some hard assessment of previous failures. It may indeed be the case that physician-assisted suicide could in the short run be confined to a few Western states. But a chain reaction from the libertarian West to the liberal East cannot be ruled out over the next decade. On the other hand, a federally focused political strategy would raise the stakes enormously. A constitutional amendment to ban the practice seems at present improbable.
These are some of the issues that the "moral flexibility" of Oregonians has brought into the world. Unlike the Netherlands, where the practice has only been tolerated, doctors in Oregon may soon begin to help their patients kill themselves with full legal support. If a further, vertiginous decline in the nation’s public morality is to be averted, we must insure that Oregonians remain the mavericks they take such pride in being.
J. P. Kenney is Professor of Religion and Humanities at Reed College in Portland, Oregon.