Penny Schlueter is suffering through the final stages of ovarian cancer, weak and ravaged from a battle fought hard but unsuccessfully with surgery and chemotherapy.

Troy Thompson is suffering as well, from the Lou Gehrig's disease that has paralyzed him so totally that he can only communicate with blinks of his eye.

Both are terminally ill, and both share a unique option: As residents of Oregon, they live in the only state that allows their doctors to help them commit suicide if and when they decide they've had enough.

Schlueter plans to avail herself of that option; Thompson will not.

For Schlueter, the Death With Dignity Act is a hard-won right, approved on two separate occasions by Oregon voters and upheld against legal challenges that went as high as the Supreme Court. The final remaining roadblock was lifted by Attorney General Janet Reno, who ruled June 5 that the Drug Enforcement Administration will not arrest doctors who write life-ending prescriptions for terminally ill patients.

For Thompson, by contrast, Death With Dignity offers horror, not relief. He is a plaintiff in a suit charging that the Death With Dignity Act is unconstitutional because it treats the terminally ill as second-class citizens.

But for now, the law is in effect. The controversy, which has played out largely on the theoretical level, has become real and personal: If you are terminally ill, will you end your own life? If you are a physician, will you help?

"It's not a legal thing now," said Dr. Bonnie Reagan, who chairs the ethics committee of her Portland hospital and serves on the task force that wrote guidelines for implementing the law. "It's personal morality now."

Four Oregonians are known to have killed themselves with their doctors' assistance. While the law requires that these suicides be reported, the state agency keeping the records has said it will not announce any figures until the number reaches 10.

Other patients apparently have initiated the process only to die naturally before they could take the prescribed drugs.

The law is designed with checks and balances to give both patient and physician an out at various points: The patient must request the prescription twice orally and once in writing. The physician has to determine that the patient has six months or less to live, and a second physician must confirm that prognosis. Then the patient has to wait 15 days before receiving the medication. The patient must ingest the medicine; the physician cannot inject it.

Dr. Peter Rasmussen, a Salem oncologist who has confirmed helping one patient kill himself, says that he expects more patients and physicians to use the law as Oregonians become more comfortable with it. But he and other supporters of the law doubt that assisted suicides will ever become widespread.

"Patients do want to live and we're usually able to make them comfortable enough not to choose to end their lives," he said. "It's extremely time consuming to go through all the hoops, talking with the patient, talking to the families."

But even if the numbers are not great, Rasmussen said, the need is there. And, even before the law took effect, there was a long-standing if unofficial tradition of doctors occasionally helping some end-stage patients die. (A recent national survey found that 7 percent of doctors said they had helped a patient die.)

"It always has gone on," Rasmussen said. "One reason I'm in favor of the law, it brings it out in public where it can be discussed in the light of day."

A cry for help

For those on the other side of the issue, the next move is simple: The law is in effect, but they can elect not to carry it out.

"I've decided I will not cooperate with it," said Dr. William Petty, a Portland oncologist. "I won't refer to doctors who will assist in suicide. I will not get involved whatsoever."

Patients have asked him to help them die: an elderly woman whose cancerous tumors kept recurring and causing her intense pain, and another patient who feared her final days would be spent in a vegetative state on a respirator.

"I find out why they're asking for suicide," Petty said. "A cry for suicide is, as everyone knows, a cry for help."

With both patients, he was able to prescribe medications that eased their pain and, while they both ultimately died, they were comfortable to the end, Petty said.

"Suicide was not what they wanted; control was," he said. "People fear losing their autonomy. There is this specter of horrible deaths that is just not true. We've all seen a bad death in our lives. That's what we tend to replay. But we have the best pain management in the world available."

As Oregon continues to grapple with the law, other states are watching closely.

"Oregon is bearing the weight for the rest of us," said Dr. Ruth Faden, director of the Bioethics Institute at the Johns Hopkins University. "For many Americans who are conflicted about end-of-life issues, there's a certain prudence in waiting to see what happens in Oregon before doing anything in their own jurisdiction."

End-of-life issues

Beyond the pros and cons of physician-assisted suicide, Faden said, is the larger issue of end-of-life care.

"My great concern is that, whatever our views are of physician-assisted suicide, we need to separate this from what we can all agree is the proper goal: improving the end of life," she said.

Faden disputes the notion, common among opponents of the Oregon law, that adequate pain management for terminally ill patients should make physician-assisted suicide unnecessary.

"It's a mistake to assume all the pain of terminally ill people can be managed through narcotics," she said. "There's still the issue of being in control of the end of your life. People who are beginning to lose their cognitive capacity, there's their dignity -- they don't want it to be reduced to below a certain point."

In Oregon, debate over assisted suicide has indeed spilled over into other end-of-life issues. The state, for example, leads the nation in the use of the powerful painkiller morphine. And, more patients are dying at home or in hospice care than in hospitals.

It is a testament to the complexity of the issue, though, that opinions continue to change. Oregon voters, when first asked about the bill in 1994, passed it by a narrow margin, 51 percent to 49 percent. Two years later, it was brought before them again in an attempt to repeal, and they instead ratified it by a greater margin, 60-40.

Surveys of oncologists have shown a decline in support for physician-assisted suicide. In 1994, 45 percent of cancer specialists surveyed approved of assisted suicide; a more recent survey showed that support had dropped to 22 percent of oncologists. Some believe the drop reflects the improvement of pain management and availability of hospice care. Others believe that, as assisted suicide begins to move into the real rather than the theoretical, some doctors are having second thoughts.

Abortion parallels

The parallels, of course, are to the ongoing struggle over abortion: While Roe vs. Wade legalized it, many doctors refuse to do the procedure. And as with abortion, the Roman Catholic Church and Right to Life have fought assisted suicide.

They argue that the law could easily be abused -- terminally ill patients, already at their most vulnerable, may be pressured to seek assisted suicide to lessen the burden on their families or their finances.

Opponents have refiled a suit against the law, claiming it stigmatizes the terminally ill and offers them less protection than healthy people. It is scheduled for a hearing in July.

Troy Thompson is one of the plaintiffs. His wife, Marilyn, now speaks for the 36-year-old, who is bedridden and paralyzed with amyotrophic lateral sclerosis, Lou Gehrig's disease.

Their opposition to the law is based on their faith, she said.

"We believe God is the author of life, and we are in his hands," Marilyn Thompson said from their home outside Portland. "When do you determine someone is eligible? At one point, it looked like Troy had just one year to live, but then the progression [of the disease] stabilized. It slowed way down. So he's gotten to enjoy so much of life with our four daughters. We're celebrating a birthday today, of the 12-year-old, and he's a part of that."

Penny Schlueter serves her side of the debate in a similar fashion, giving a human face to the issue of assisted suicide.

She is 56, a retired economics professor whose personal struggle with cancer coincided with the raging public debate over Death With Dignity. She decided to lend her support.

"It's very important to me," she said simply. Until Reno issued her ruling on whether DEA agents would target doctors who wrote prescriptions for fatal doses of medicine, Schlueter worried that she would put her physician in legal jeopardy by requesting assistance. Now that barrier is gone.

Schlueter, who lives outside Eugene, is not rushing the next step. For one thing, her doctor has told her she probably has longer than six months to live. But knowing the law is there has helped ease what may be her final months.

"I do intend to pursue it," she said of the assisted suicide option. "Even if I end up not using it, it's there."

Pub Date: 6/22/98