PASSAGE of an assisted-suicide measure in Oregon pushes the United States onto uncharted political and ethical ground.
The ballot question, which allows doctors to provide a lethal prescription to consenting adult patients diagnosed as terminally ill, is profound in its implications.
And just as abortion became the focus of a long and difficult legal struggle 20 years ago, assisted suicide is likely to follow suit, particularly as more states are expected to follow Oregon's lead.
``There's nothing that happened in this election that was more important,'' says Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania School of Medicine in Philadelphia. ``No one will remember who was in the 104th Congress 10 years from now, but everyone will remember the first state to make assisted suicide legal.''
Oregon's ``Measure 16,'' which passed last week with a 52 percent majority vote, is the next in a series of steps that proponents say have occurred to make assisted suicide more acceptable.
Four years ago, Jack Kevorkian, the controversial Michigan physician, began helping patients commit suicide. So far, he has provided the means and taken an active role in the deaths of 20 people - usually in the back of his old Volkswagen van.
In two state elections since then - Washington in 1991 and California in 1992 - voters faced measures that would have allowed doctors to administer lethal injections to patients who requested them.
Both measures, which contained what advocates said were safeguards against abuse, failed by 54 percent to 46 percent margins, despite preelection polls indicating most people in those two states favored the measures.
The Oregon measure puts even more of the responsibility on the patient, who will have to request a prescription, obtain the pills, and ingest them.
``It's important to acknowledge that it is the patient who is empowered by this initiative and not the physician,'' says Peter Goodwin, a Portland, Ore., medical doctor who worked for passage of the new ``death with dignity'' law.
The law applies when a physician determines that an adult patient has no more than six months to live. It requires a second physician's opinion, three specific requests from the patient (one in writing), professional counseling, and a 15-day waiting period.
Under the law, physicians and pharmacists may refuse to play any role in suicide if their conscience so dictates.
Still, the law has deeply divided the medical community. A key tenet of the Hippocratic Oath sworn to by physicians is: ``I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect.''
While the Oregon Medical Association did not take a stand on the measure and a significant number of doctors, nurses, and other medical professionals here publicly supported it, the American Medical Association opposed it.
``Right-to-life'' groups, former US Surgeon General C. Everett Koop, and a variety of religious faiths worked for defeat of Measure 16, but most of the opposition came from the Roman Catholic Church.
Catholic leaders appealed for funds from local parishes and sources outside the state; opponents out-spent backers 3 to 1.
Crossing ethical lines
It is unclear what opponents will do now. In a statement, Archbishop William Levada and Bishop Thomas Connolly of the Oregon Catholic Conference predicted the new law would ``lead to the deaths of untold numbers of weak and vulnerable persons.''
``We are very concerned at the prospect of what lies ahead for Oregon and the nation now that the first state has crossed the moral, medical, and legal boundary line against killing people who are terminally ill,'' they said.
In California, efforts are under way to introduce an assisted-suicide measure patterned on Oregon's. Bills are being drafted in New Hampshire and Iowa as well.
Meanwhile, legal challenges have been mounted against state laws outlawing assisted suicide. (Thirty-two states explicitly criminalize assisted suicide; 11 more states treat it as a crime under common law.)
Earlier this year, Washington State's law banning physician-assisted suicide was ruled unconstitutional.
In her decision, US District Judge Barbara Rothstein in Seattle said that the constitutional right to equal protection safeguarded the right of terminally ill patients to end their lives with the help of a physician. Judge Rothstein likened the issue to the right to abortion, as affirmed in the 1992 United States Supreme Court decision upholding Roe v. Wade.
The Washington State case is now pending in the US Ninth Circuit Court of Appeals in San Francisco. A similar case is being argued in a federal court in New York.
Lawmakers, legal authorities, the medical profession, and the public are moving very cautiously in this area. Still, 73 percent of those surveyed in a national Harris Poll last December favored doctor-assisted suicide.
That number has grown since similar polls were taken in 1982 (53 percent) and 1987 (62 percent).
One of the main concerns remains whether patients whose prognosis is terminal would seek suicide in order to avoid high medical costs for their families.
(This is particularly true in Oregon, which has pioneered a plan to ration health-care procedures in order to provide Medicaid coverage to all eligible people. Gov.-elect John Kitzhaber is a physician who authored the plan as state Senate president. Dr. Kitzhaber opposed Measure 16, however.)
``I'm going to oppose these laws as long as economics looms as a driving factor in the minds of people who are thinking about ending their lives,'' says Dr. Caplan, whose latest book, ``Moral Matters: Ethical Issues in Medicine and the Life Sciences'' has just been published.
For years, doctors in the Netherlands have been performing voluntary euthanasia without fear of prosecution, and last year the country officially decriminalized the procedure.
But Oregon is the first place to write into law the means for doctors to do so.
That this state is the first to explore this unfamiliar political and ethical world is not surprising. Long known for electing maverick politicians and making use of ballot initiatives, Oregon is described in the Almanac of American Politics as ``an experimental commonwealth and laboratory of reform.'' And of all states, it has the lowest rate of church membership.