The letter below was written by a pharmacist in the hope that Brittany Maynard will see it. It is heartfelt, and also full of facts that she should know.
Dear Brittany Maynard:
I am publishing this in the hope that it will be seen by you since I do not know how to send you this message. That is my main purpose. In this message are facts you probably have never heard and you should weigh them before proceeding further.
From what I have read you have chosen, because of your medical condition, to move to Oregon, to end your life as envisioned by their law to use self-administered medications. Others have done this and I have not written them probably because I did not even know of their situation. I am writing you because you have chosen to make your life and death a public one and one that will surely influence the feelings and decisions of the others we may never know of who need to read this. I am writing you to ask you to reconsider how you are going about the ending of your life in such a public manner. I am hopeful that you will take the time to consider what I have to say to you and to those impressionable people you will influence because you are who you are. I also want you to c0nsider cold, objective medical facts from a pharmacist, facts often ignored by advocates of “Physician Assisted Suicide (PAS)”.
I am a retired pharmacist with many years of practice and with knowledge of the drugs that people use. None of these drugs were ever developed for the purpose of killing someone but as we all know they have long been used by people choosing to take their own life. This has happened in all states and not just in those which have made PAS legal. From this wrongful use of medications has flowed much suffering and heartbreak from the suicide and suicide attempts whether legally sanctioned or not.
I heard this morning and am thankful that you have decided not to go through with your November 1st decision to attempt to end your life. I know you are still determined to do this but hopefully you willc onsider the things I have written here, especially as they relate to the effect on others. There are two issues. The first is your personal decision to end your own life. The second is the impact that you will have had on others and on the state of the law in the US and maybe even the world.
I know that many people from many perspectives have either supported your personal decision or have argued with you against it. I want this to be different from either of those and while I want you to consider my opinion in your personal situation, I even more want you to focus on the situations of others you will influence. You are certainly a bright individual who can understand that those affected by your choice to go public with your death might not fit into the same situation you feel you are in. In fact your influence will be much broader and could even encourage those who are not terminal to end their lives outside of the legal structure set up in states like Oregon and others that will come.
It is the public manner of your impending death, your personal appeal to many, the fact that you moved to Oregon to utilize the PAS law there and those that seem to be encouraging you in this regard that compels me to write to you. I do not want to criticize you or demean in any way how you are feeling and what you are going through. No one can take issue with how you are feeling in not wanting to go through what you are expecting. No one who is not in your shoes should do that. Where it gets muddy is when your personal decision gets politicized and utilized by pro-PAS organizations. The fact that an organization like “Compassion and Choices” is involved in your support and communication of your situation does put the spotlight on you in a different way because of their mission to expand PAS to all other states. While I understand you agree with this mission based on your knowledge of the broader issue of availability of PAS, I also believe you have not gotten all the facts that you should be considering especially from those whose chosen role is to advocate for people to be able to choose death if they wish in a manner prescribed by the state. You do need to consider other facts. I am from Vermont and from what I see that has transpired here is the passage of a bad law that was supported by pro-PAS groups no matter how bad the law was. (Vermont is the perfect example of this and will be discussed later and I think you would agree that such a law as we have here is not good.) Considering how the law has unfolded here in Vermont might give you a different opinion of those promoting such. Again, I will discuss that later.
Not all situations are like yours and not all people have the mental ability to decide such a serious matter rationally as you seem to have. The people that will be influenced by you are very vulnerable. They may have serious diseases, could be mentally ill and depressed and those who are disabled. I am fearful for the message your case will send to people struggling with illness but who are not terminal and to vulnerable and emotional teenagers who contemplate suicide because, unlike you, they find no good reason to want to live. We must reach these teens but not with a message that death is an answer. This is what I think you should give serious thought about. Not the politics or the law but the people affected. I know you do not want to do harm but you may not have adequately considered the harm that will come to those people in many different situations who are hurting but could be helped if reached before they kill themselves. It is the collateral damage to many for years to come from your public death that is the main issue here and I hope that if you have not considered this before you will now. Please do not leave this world with such a legacy!
In appealing to you I do need to discuss my feelings about organizations who promote PAS. I would like to stay away from this but the fact that they are involved in your situation makes it necessary. These are my thoughts and I believe if explored you will see there is some basis in fact for them. They sell the lie of how simple, humane, effective and quick it is to end your life. The argument that all they wish to do is to give an option to a suffering person to have control of their life and the end of it is also false. If they really wanted the best for people they would insure that there is not under-reporting or no reporting of the complications and horrors that occur for a certain percentage of people who utilize the law. Such lack of reporting is apparent in the Oregon annual report process. In Oregon since 2010 there is very little collection of data on complications experienced during the medication ingestion death unless a physician is present and in 2013 of the 71 who died under the law, only 8 of them had a physician present. The pro PAS advocates instead of working hard to make sure that the end result is in the best interest of the patient by being open about the complications and suffering the suicide attempts cause instead ignore and obfuscate the truth. They fail to point to the statistics from Oregon that 59 patients who died in 2013 had an “unknown” next to their case file on whether they experienced any complications during their death. Yet from experience in the Netherlands and elsewhere it is clear that many of those 59 had to have had serious complications.
Under Oregon law the physician must tell you of the “the potential risks associated with taking the medication to be prescribed”. What the physician must tell you is not spelled out in the law specifically. You may be the only one who knows what the physician has told you. There is no way that we can know if it was accurate so I want to give you my professional understanding to consider. For years surveys done for drug magazines indicate that the profession of Pharmacy was the most respected, even more so than clergy and doctors. Pharmacy customers regularly tell us that we know more than doctors. While not necessarily true it is true that pharmacists are dedicated and know a great deal about the drugs they oversee in dispensing and that is what I want to share with you.
Under Oregon law the physician is free to choose what medications are to be prescribed for your death. So not knowing exactly what will be used, I must discuss the most often used and those are barbiturates. Regardless of the medication used there is always the possibility of problems occurring in their administration. That is why we refer to physicians “practicing” medicine. A great deal of what is done is “trial and error”.
You possibly have been told that self-administering the chosen drug will result in an effective, quick and final departure. There is no question that certain barbiturates if taken in sufficient quantity can cause death and have accomplished that for some. These drugs were never developed to kill but to help people and in the dosing for proper or improper use there are many variables (patient age, sex,
weight, overall medical condition, recent food or other medications ingested, individual sensitivity to medication and more) that will necessitate differing amounts of the drug. Potential tolerance must be taken into account. Physicians, however, have not been schooled on how to take these many patient variables into account when writing a lethal prescription. They will make mistakes which will cause patient suffering. In some cases, this shortcoming will result in prescriptions written that are insufficient to cause death. I doubt if that such a mistake will be made in your carefully monitored case but when this death scenario is played out over and over across the nation there are so many who will not die but will experience problems not expected. There will be exaggerated responses to the drug because they are receiving a larger dose than is recommended for “intended medical” purposes but will not receive enough to kill them. Just think about the failures recently of drug dosing for inmates on death row. Very monitored but still problems arise.
The Oregon law does not require a physician’s presence. It only requires a report on complications when one is present. “Unknown” is often what is reported on the subject. A physician can be present and I would assume that with all the attention and encouragement being given to your case by C&C and others advocating for an expansion of the law in all states, that you will be carefully monitored and watched by a physician and possibly more than one. Your situation that will be covered by the press and followed by so many will not be the typical life ending event that others who choose to die this way willexperience. I may sound cynical and this may seem cruel but certain of the people who are encouraging and praising you probably care little about your life and more about your death and how it will further the spreading of their cause to all other states.
So many will be alone in a dark room, scared and feeling abandoned. Some may have loving relatives and friends with them but few will have physicians. All will face the possibility of a failed attempt. A very definite certain percentage of those alone will botch it and no qualified person will be there to help them. And what help could be provided in any event? Alone or with trained medical workers, if one slips into a coma or falls and cracks their head and becomes unconscious, nothing can be legally done to further their suicide attempt. Euthanasia is not legal in our 50 states and so unlike the Netherlands where a physician can follow-up with a lethal injection for those 18% who have been proven to fail in their self-administered attempt, no such thing can be done in the United States. While you will probably be protected against a fall or other such accident, you still could have an untoward reaction to the drug and it may not kill you but create a worsening health situation for you.
It really is hard to cause death sometimes. There will be those times when the body will not allow it to happen. The lungs and heart will keep working, the drug will wear off and the horror of the overdose side effects will begin. Many who choose this method to die will fail and such failure will result in greater suffering and a prolonged life of misery for them and their loved ones. In some cases because of the damage done another attempt using medications might not be possible.
It is reasonable to assume the patient who has received a lethal prescription will have their mind filled with many thoughts as they prepare to surrender their life. If they would have had compliance problems without such a stress, it is not difficult to imagine that the problem is compounded by their state of mind. There are physical limitations some have as well that would affect compliance. We all know of people who for no apparent reason have swallowing problems when it comes to medication and others have certain neurological illnesses that create swallowing difficulties. Others may have problems using their hands. They may have tremors or severe weakness that while they may be able to begin taking the drug, they may not be able to complete the ingestion of the total lethal dose by themselves.
Patient medication dosing compliance has been such a problem that the practice of pharmacy has evolved over the years to require that a pharmacist offer each patient getting a prescription the opportunity to be counseled on its use. Even the simplest instructions and directions can create major compliance problems for some people. It is not uncommon that there is a caregiver to handle the patient’s medication to insure compliance. This is even more needed with the elderly. In nursing homes and other extended care facilities, nurses use established procedures to insure the patient is compliant. It is not difficult to imagine any of these above described persons getting a lethal dose of medication prescription and having major difficulty in taking it. Yet the Oregon law, recognizing possible coercive problems, requires the medication to be administered by the patient without assistance. As naively understandable as that rationale might be, it leaves most patients very vulnerable to some real and serious practical dangers.
If not dosed properly the patient might have problems such as gasping or muscle spasms causing them to suffer greatly. They may lose consciousness before they complete the dosing. They may then awake experiencing some of the many major side effects of the drug. The drug may cause them to feel panic or terror. It can cause confusion. They can experience orthostatic hypotension, fall and hit their head. They may end up in a coma and not die at all from the drug. Imagine the horror of that and for a loving family member who might be alone in the room with the patient and sees all this happening before their eyes and not know what to do.
The drug can cause them to vomit and they could aspirate the vomitus. If they vomit before the medication is absorbed they may now not have the sufficient death dose but enough to create major side effects. Vomiting is not an uncommon side effect for many drugs including barbiturates. While physicians may give you medication to prevent vomiting, this is not done in all cases and even if given may not work. It is possible that the person who starts to ingest this medication is already feeling ill (as you did the day after visiting the Grand Canyon) and if cancer is involved, has nausea and other physical upsets in the first place. It is not hard to imagine that they would begin to take the medication, gag, possibly swallow some or all of it then get so sick before the drug kills them that they vomit. In their weakened state they may be unable to deal with the vomiting, some will aspirate the fluids that come up. This can create pneumonia and at a minimum will cause much suffering and distress.
Patients may have an allergic reaction to the medication resulting in difficulty breathing, rashes, edema and suffering, all happening without them dying. Some people experience agitation, irritability orexcitability, aggression and even increased sensitivity to pain. Others may lapse into a coma and linger and suffer for a prolonged period.
While you will probably be closely monitored some will not be and could even experience some very strange reactions. Some under the influence of large doses of such sedatives and hypnotics have actually gotten out of bed and have “sleep driven” a car or have done other unconscious activities. If taken with alcohol or other drugs, these side effects can be more exaggerated. You may be aware of drugs such as amphetamines that can cause hyperactivity in some and in others can cause sedation. People do have varying responses to different drugs and that is a very real possibility for those who take drugs like barbiturates, get an overdose, don’t die and then become conscious.
It seems apparent that you are hoping to have an impact on the system and on what others think. You seem to want a world where others will be able to end their life as you are planning on ending yours. What you may not have considered are the many variable situations mentioned earlier that differentiate their case from yours. While you think your situation is hopeless (although having hoped for a miracle), others might not be as severe as yours and yet in a state of depression or having been subjected to undue pressure, might latch onto what you are saying by your departure, to bring them to a the point of making a request to end their life. From what I have read about you, I feel confident in thinking that you would not want one of those folks to use your death as their incentive to unnecessarily end their life. There have been so many cases where the imperfect or inaccurate diagnosis of a terminal disease has been made. Cases where people have recovered and cases where they have long outlived the six month prognosis required before the law can be utilized.
There have been situations documented where folks have ended their life so as not to be a burden on their family and have been encouraged to do so by the same. Indeed some will use the PAS law to commit murder. One would have to be blind to the current condition of our society and the cruelty that is inflicted on others to deny this. Even our relatives are not immune from such. While they should be receiving our loving care they are often mistreated and neglected by their own. It is then just a small step for such people to take advantage of a law intended to be caring and compassionate to commit an unspeakable act against a loved one. There is another reason to point to the less than caring reason for such laws. PAS gives an opportunity to a profit-driven corporate healthcare industry to increase their bottom line by having this as a mechanism to do just that, increase their profits. It is much cheaper to provide a one-time charge for a lethal dose of medication than to provide the expensive care to the same person for months and possibly years to come. Much has been written on this and Oregon even provides an excellent example of two people who wanted to be treated and live but were denied the treatment and at the same time offered a lethal dose of medication payment.
Troubled teens and others will be influenced by your decision and your public support of PAS laws will be furthered by your story and will help those who wish to see similar Oregon based laws passed in all other states. By now I hope you can see that these things are not positive and the legacy you will be leaving behind if you persist in the public display of your death will be one of increased pain, horror and death for undeserving and vulnerable and impressionable people. My home state of Vermont attempted to pass legislation patterned after Oregon but when that seemed doomed to failure, the death lobby was willing to accept any death legislation no matter how flawed it was, with or without the supposed Oregon safeguards. These supporters of so-called “death with dignity” point to Oregon as the ideal law and yet they still applauded the compromises of a couple of Vermont Senators to break the tie in the decision of the legislature to pass into law any death bill even if it was stripped of the Oregon safeguards. That compromise resulted in a law that so many have labeled as “legislative malpractice”. While I believe that reliance on these supposed Oregon safeguards is illusory, death promotingorganizations were more than happy to support this defective and dangerous legislation to become law in Vermont without those safeguards so they could have another state on their list that allowed PAS. That law also provides that in just two years its provisions will sunset and all that will be left in its place is an “immunity provision” for physicians as they are allowed to pursue a death practice withoutlimitations or safeguards. Brittany, just imagine the abuses that will occur when that time comes. There is joy in their camp that they have you (a bright light be it a misdirected one) to put forth their
message (a dark one) in such a way that brings their desired results in other state legislatures. Please reconsider what you are doing for the sake of yourself and many others. It is good that you have postponed the November 1st date for your death. This will provide you with more time to consider the objective reasons why this public exit is wrong and possibly why you should reconsideryour death in this manner.
So what am I suggesting to you? Pull back from the spotlight. Make your situation as private as you can. Do not be rushed into ending your life because of outside pressure. Take all the time you need to receive counsel on this and if you do decide to pursue this course do not make it a public spectacle that will encourage others to do the same or will further the goals of a death culture instead of the bestinterest of the suffering patient. Think of the troubled teens who are watching what you are doing and the message you are sending.
Death as envisioned by the Oregon law is one of an effective, humane, quick and final departure. This will not be the case, however. Many will fail in their suicide attempt. They will botch it and it will result not in death but great suffering. It can prolong a life of misery. It will be more than the patient who will suffer. Families will be devastated when this happens when they see their loved one linger in such a way. People will be influenced by your death who do not qualify to participate under the law because they will interpret your death as a way out of their hard situation as well. I don’t believe you would want that and possibly have not considered it. It will happen.
Please do not be a part of such a process and legacy that will never end but will from time forward result in the unnecessary death and suffering of so many people.
Robert L. Orleck
P.O. Box 174
Randolph, VT 05060