GMO.M.G: Why Genetically Modified Organisms are Also Not Like Sodium

tomato by W_Minshull is licensed under CC BY 2.0

After similar measures have failed in Washington (45% yes to 55 no) and California (49% yes and 51% no) in 2012, Oregon stands to become the first state in the country to implement a measure requiring the labeling of some genetically modified foods.  If passed, the measure would take effect January 2016.  Vermont, Maine and Connecticut have also approved labeling laws, but these have not gone into effect yet.  

Genetically modified organisms (GMOs) are made by splicing genes from plants, animals, and sometimes even bacteria, viruses, fungi, etc. together to produce food products that could not occur naturally.  Not only could these foods not occur in nature, they could not be produced by the type of cross-breeding that farmers have engaged in for centuries (for those of you thinking back to your early genetics lessons and remembering old Gregor Mendel breeding green pea plants with yellow pea plants).

There could potentially be as many genetic modifications as there are genetic combinations.  The possibilities are literally infinite.  Big agri-business companies have proposed a number of possible uses for GMO foods.  GMO wheat, rice, soy, corn, and grain could be engineered to provide increased nutrition, larger crop yields, and resistance to drought, pests, blights, and the like.  Not only could these crops make more food more widely available around the world, the plants themselves could be engineered to contain more nutrients or have other medicinal qualities.  In addition to these substantive changes, more superficial benefits could be derived from genetic engineering, particularly for fruits and vegetables, which could be given longer shelf-life, richer flavor, even something like phosphorescence to make them more attractive to kids. 

However, many of these potential benefits have not panned out.  Genetic engineering has so far been used primarily by major corn producers to engineer a product that is resistant to the primary pesticide used by these companies.  Some other plants have been engineered to produce their own pesticides.  Not only has the promise of the benefits of genetic engineering to humankind been slow in coming, there are obvious environmental consequences to making plants able to withstand more Roundup and others able to produce their own version.  The effects of these engineered plants on human health may be relatively unknown (because the chemicals and the genetic science are proprietary, independent studies of their effects haven’t been permitted), but the negative effects on the environment are easy to foresee.  Insects such as moths and butterflies are impacted by the pesticide-producing plants.  As their populations decrease, so will those of the birds and other species that feed on them, creating an inevitable ecological ripple effect.

So, as you can see, there are really good arguments both for and against labeling genetically modified foods.  They are just not any of the arguments being put forward in the For and Against Measure 92 campaigns in Oregon right now. 

The argument against is your basic “big government” argument, which is never persuasive to me.  I love big government.  The more government jobs there are, the more likely it is that I could eventually be hired to do one of them!  The other major No on 92 argument is that it will increase costs for farmers and consumers.  I am also not particularly persuaded by the “increased cost” argument.  First of all, it is fishy how lacking in specifics it has been.  The “No” side really hasn’t given any dollar amounts for how much it is going to cost farmers and grocery shoppers to have foods labeled, they just want us to know it is going to cost us jobs and make things harder for middle class families to put food on the table.  What doesn’t?! 

According to Oregon Right to Know (the “Yes on 92” folks have much more specific cost data than the “No” folks) the cost to the taxpayer of the labeling measure is less than one penny a year, and the research firm ECONorthwest found the median increase to the consumer would be less than $2.30 per year.

The arguments in support of Measure 92 have irked me even more than the arguments against.  They have struck me as patronizing and nonsensical, more like propaganda than genuine argument.  For example, I can’t tell you how many of the pro-92 ads mention Agent Orange.  What is the link between Agent Orange and GMO labeling?  Well, it takes a minute to get there.  Because most of the genetic modifications that have been implemented on a large scale so far have had to do with the pesticide properties of plants, and because the technology is proprietary, the companies that have conducted the safety testing are the same major agri-chemical companies that benefit from their widespread use (because of the chemical pesticides that can then be sprayed on them in great doses).  This isn't to say that the companies doing the genetic modifications to food products are the same companies as those that made Agent Orange and DDT.  Rather, Agent Orange was just another herbicide produced by an agri-chemical company back in the day, which might be one of the companies testing the health effects of GMO foods.

I find the use of the magic words “Agent Orange” as a scare tactic patronizing and insulting to the intelligence of Oregon voters.  GMO labeling by itself will not do anything to reduce the use of chemical pesticides, increase access of independent health studies to proprietary agricultural technologies, or actually indicate how much of what, if any, pesticides is used on the food product in question.  The genetic modification of the food product is totally separate from the question of whether and what pesticide was used on it (unless it is one of the ones that produces its own pesticide, which the label will NOT tell you!). 

It is actually even a little misleading to invoke Agent Orange in this context.  To say “we don’t know anything about the health effects of GMOs but the companies telling us they’re healthy are the companies that made Agent Orange” isn’t the whole story.  Oregon Right to Know admits: “a team of Italian scientists came up with nearly 1,800 studies of GMO foods (the majority of them independent of any GMO-related funding source) done between 2002 and 2012 and not one of them found any evidence of negative health effects from consuming GMO’s.”  They go on to say that regardless of these results, consumers still have the right to know about GMOs in their food.  Even so, to have this information and still push the chemical company horror story strikes me as disingenuous.

One could even argue that labeling will discourage agri-business from pursuing the beneficial aspects of genetic modification discussed above because foods that are genetically modified to contain more nutrients or to have medicinal qualities will bear the exact same label as the pesticide soaked GMO-labeled foods now associated with Agent Orange.  For example, it is probably possible to genetically engineer a tomato to contain more lycopene, which occurs naturally in tomatoes, and helps prevent cancer.  If it turns out that engineering a tomato to produce its own pesticide does have a carcinogenic effect on human health, then the GMO label has become completely meaningless.  The cancer fighting tomato and the cancer causing tomato will both be marked simply “GMO”.

The other main argument in support of Measure 92 centers on the voter’s “right to know.”  The Oregon Right to Know Yes on 92 Pocket Guide states “We have a right to know important information about the food we eat and feed our families – such as sugar and sodium levels, whether flavors are natural or artificial, and if fish is wild for farm-raised.  We should also have the right to choose whether we want to buy and eat genetically engineered food.”  A couple things here that I find irritating.  As I highlighted in the title of this post and explained above, genetically modified organisms are not like sodium.  Sodium, whether you find it in canned soup or cheese or tomato paste is the same chemical.  Genetically modified foods is a broad category of many different products, modified from their original genetic makeup in innumerable ways.  We know the effect of sodium – in different amounts – on our health.  The presence of a GMO label tells us next to nothing about what is actually in the food product (what has been modified, how it has been modified, why, and to what effect on the consumer).

The presumption that knowledge that our foods contain GMOs will let consumers “choose whether we want to buy and eat genetically engineered food” also strikes me as a little naïve (to be charitable) or coming from a place of privilege (if we’re being less charitable).  If Measure 92 passes and is implemented, a huge percentage of the foods in regular supermarkets (estimates are at least 70-80%) are going to be labeled GMO.  Basically everything containing corn and soy probably will be, which is basically everything in a standard grocery store. 

The idea that average consumers will be able to somehow “opt out” of GMO foods is like saying that anyone can eat organic if they want to.  It just isn’t an economic possibility for most shoppers, at least in rural areas of the state.  If you’re already stretching your monthly EBT allotment to cover your family of six, you aren’t going to be able to jaunt over to your your nearest Whole Foods (of which the only one is 20-40 minute drive away) for non-GMO products and stay on budget.  Instead, you are going to have to feed your five kids the food you pick up on sale at your regular corner store…the stuff with that GMO label on it that you vaguely remember from election time has something to do with Agent Orange.

Measure 92 could pass.  Over the summer, an OPB poll found 77% of voters in favor, but this number has declined as advertising against the measure has ramped up.  As with other progressive measures, it is struggling in the conservative area where I live, but slightly carrying the state overall.  At the end of September, a poll found 54 percent of the voters supported the measure with only 16 percent opposed.  Despite my arguments above against the arguments in favor of the measure, I am going to vote for the measure itself.  I am not convinced the cost will be significant and it puts the GMO issue into the public’s mind in a way that can lead to debate about the actual issues of real significance for human and environmental health that we really do need to be talking about regarding GMOs.  But I also think Monsanto is probably doing backflips that so much time and energy and money is being thrown into this essentially meaningless labeling fight.  Agribusiness is thinking “yes, please, devote yourselves to that sucking void of a pointless mission so you’ll have fewer resources to fight the real fights.”

But the main reason I am voting in favor of Measure 92, despite obviously loathing so much of the argument and advertisement that has been put forward so far in support of it is because its supporters have finally settled on an inordinately compelling argument.  Perhaps playing to the conspiracy theorist in all of us, Oregon Right to Know is circulating a simple graphic showing who holds the purse strings in the “No on 92” camp:

Source: http://oregonrighttoknow.org/no-on-92-coalition-donors/

The message seems to be, basically, if Kraft, Coke, Pepsi, ConAgra, Cargill, DuPont, General Mills, Hormel, Kellogg’s, Monsanto and Land o’ Lakes are willing to pour millions of dollars into defeating this measure, then Oregonians should support it.  We just might.

Why Shari’a is not like Sodium (and other things Bill Maher doesn't seem to get about that Pew poll)

In the Bill Maher vs. Ben Affleck throwdown, and the subsequent, painful Reza Aslan vs. Sam Harris tête-à-tête that has been playing out in the news and social media ever since, much has been made of the 2013 Pew Research Center poll of Muslims around the world on their religious views.   Maher and Harris are using the results of the poll to support the argument that Muslims believe dangerous ideas and that therefore Muslims are dangerous.  Maher and Harris point to the poll to show that, contrary to the claims of liberal apologists, it isn’t a minority of extremist bad actors on the fringes of the global Muslim community that ascribe to equally fringe extremist beliefs, but rather that the poll shows these beliefs are central, and ascribed to by the majority of Muslims.  As Maher put it, “Islam is the mother lode of bad ideas.”

As a side point, I strongly disagree.  I think it is fine to criticize ideas, but this isn't what they are doing.  They aren't saying "stoning adulterers is wrong."  No matter how much they claim not to be saying this, what they are saying is that all of the people who believe in Islam are bad/dangerous.  They are ignoring the fact that people can be totally inconsistent in their beliefs.  They can believe in religious freedom and believe in the death penalty for apostasy.  People are imperfect.  We are inconsistent.  We aren't always great religious adherents either.  I had plenty of cab drivers in Egypt with the zabiba, the forehead marking that identifies someone who prays so hard they develop a callous on their forehead from touching it to the ground so forcefully who tried to pick me up.  People are hypocrites.  Not only do we frequently hold inconsistent and competing beliefs in our hearts, our actions do not always follow on our beliefs, no matter how sincere those beliefs may be.  So to equate belief with actions, as Maher and Harris do, is absurd, and unfair (and discriminatory) because they are obviously applying that ridiculous standard only to Muslims. And to intentionally ignore the broad range of responses in the Pew poll's results (which proves Aslan's point that "Muslim countries" are a many and varied thing) and overgeneralize their discriminatory assumptions to all Muslims is bigoted and intentionally misleading.  Beyond my personal feelings on this point, though, it is also clear to me that Maher and Harris are reading more into the Pew poll results than the poll can really tell us.

I have argued elsewhere (okay, mostly on Facebook) that we cannot make sense of the Pew poll numbers without some national context.  Maher at one point declared that 90% of Egyptians thought that the death penalty was an appropriate punishment for leaving Islam. He seems to be rounding up the 86% which the poll found, but he didn’t read the fine print explaining this was 86% of the 74% of Egyptian Muslims who thought that Shari’a law should be enforced as the law of the land, so the actual number of Egyptian Muslims who the Pew poll found think death is the appropriate sanction for apostasy is closer to 64%.  Which is still shockingly high… 

Until you consider that an Egyptian can receive a death sentence for being one of more than 500 people arrested at the same protest where a single police officer died.  Or when you consider that an Egyptian can receive a 15 year prison sentence for breaking curfew.  Or 1 year in prison for insulting the president on your blog.  Or 7 years in prison for being a respected journalist for an international news outlet that the government claims is a member of the Muslim Brotherhood, an organization which, up until last June was the elected government.  So if these supposed “crimes” carry such heavy sentences, handed down by the legal system, isn’t it at least possible that the general Egyptian population at large, regardless of religious identification, might have a skewed idea of what kinds of crimes warrant serious punishment?  In order to make sense of that 64%, wouldn’t we have to know what crimes the entire Egyptian population think justify a death sentence?  And, to understand whether these beliefs are common only to Egypt’s Muslims, shouldn’t we also be asking Egypt’s Copts (the Christian minority) how they feel about the proper penalties for serious transgressions of their religious laws?  Only once we know how Egyptians at large would answer the polling questions, and how other religious groups in the same country would respond, can we understand the responses of Egypt’s Muslims in context.

These are criticisms about process, logic, and argument, which anyone listening to Maher and Harris can pick up on in their statements and go, “wait, that doesn’t sound right.”  Critics have already attacked the statistical conclusions Maher and Harris are drawing.  As Christopher Ingraham at Wonkblog rightly noted “Maher tries to speak in broad brushstrokes of a ‘global Islam,’ but Pew's data show that such a thing doesn't really exist.”  However, the information the Pew poll presents about Shari’a law may be a little more difficult for Western listeners to parse.  It would be easy enough for a non-Muslim reader to look at the Pew results and conclude that the majority of Muslims the world over favors the implementation of Shari’a law either as the official law of the land, or in at least some part of their country’s legal system.  It is clear that a striking majority of Muslims in countries that seem to a non-Muslim viewer as otherwise modern and secular, with strong Western ties, believe that family law and property disputes should be decided in religious courts (94% of Muslims in Egypt, for example, and 93% in Jordan for example).

The Pew poll does an excellent job of breaking out a number of viewpoints, not only the question of whether Shari’a law could apply only to certain areas of the law (and also considering whether these areas are already decided by religious courts in the countries surveyed), but also querying respondents as to whether Shari’a, if made the official law of the land, should be so enforced as to Muslims only (during Muhammad’s rule of Medina, his constitution afforded non-Muslim “people of the book” the right to practice their own religion in return for political loyalty and taxes).  However, what the poll cannot show is what respondents mean when they hear “Shari’a.” 

There is actually tremendous range in responses in the poll as to whether Shari’a should have single interpretation or should be open to multiple interpretations, which already shows that it is interpreted in numerous ways.  For example, in Afghanistan, where 99% of the Muslims surveyed favor making Shari’a the official law of the land, 29% believe Shari’a should be open to multiple interpretations.  Think about that for a minute.  In the context of what has been said recently following the Maher/Affleck discussion (and what is always said whenever Shari’a law comes up), that is some shocking stuff.  In a country where almost all of the Muslim population wants Shari’a law imposed, almost a third think that can mean different things.  And that is just within one (conservative) country. 

I think Maher and Harris would have us believe that “Shari’a” is one monolithic (obviously bad) thing.  Shari’a is, from what Maher said on his show, burkhas, stoning adulterers and apostates and killing cartoonists.  Whether the average American necessarily believes that Shari’a is those particular things, I think that even an educated listener to Maher’s show or a casual reader of the news on this topic might reasonably believe that the Qur’an and Shari’a are one in the same, or that all Islamic law comes from the Qur’an.  We might think that whatever differences there are in Qur’anic interpretation are little grammatical tweaks, similar to the variances in different versions of the Bible, like how 1 Corinthians 13:4-7 is “Love is patient, love is kind. It does not envy, it does not boast, it is not proud,” in the New International Version and “Charity suffereth long, and is kind; charity envieth not; charity vaunteth not itself, is not puffed up,” in the King James Version.

I think a reader not particularly familiar with Shari’a, or familiar only with Christian religious doctrinal interpretation, might be surprised at the range and complexity of Islamic law sources and interpretive frameworks.  Shari’a isn’t a single monolithic thing.  Shari’a is not like sodium (cue the well-deserved stream of annoyed messages from chemists about how complicated sodium is).  It cannot be expressed in a stable chemical formula, or written in a single text, crystallized in one hardened, immutable set of ideas.  It isn’t the same the same from country to country, language to language, community to community, or mind to mind.

Shari’a is divided into primary and secondary sources, afforded varying levels of authority.  The Qur’an is considered (as you can see from the Pew poll results) by most Muslims to be the revealed word of God and is believed to have been transmitted to Muhammad by the Archangel Gabriel over roughly 22 years.  The verses within the Qur’an amounting to legal injunctions (and it is debated exactly which and how many of these there are) form the primary source of Shari’a, which means “right way” or “path.”  These verses categorize which behavior is compulsory, forbidden, discouraged, permitted, and rewarded.  In addition to these specific legal injunctions, many verses of the Qur’an outline general principles, which have been interpreted by jurists in subsequent centuries.

The Sunnah are collections of the recorded sayings (hadith) and traditions of the Prophet Mohammed during his lifetime to explain the legal injunctions set out in the Qur’an.  The Sunnah are secondary in authority to the Qur’an because they are the Prophet’s take on it, and not the literal word of God.  This means that any contradiction is resolved in favor of the Qur’an.  If neither the Qur’an, nor the hadith explain a verse, the writings of the companions of the Prophet, the Sahaba, which will often contain explanations of the traditions of the Prophet, can be consulted for guidance in interpreting the Qur’an.

It took around 300 years after Muhammad’s death for the Sunnah to be completed.  Some of the hadith that are included in some versions are omitted from others.  To resolve inconsistencies, scholars have developed a tradition wherein every collection of hadith has been rounded up and the authenticity of each saying is assessed or ranked by the number of times it appears in all the collections.  Certain compilers get reputations as being more reputable, such as Imam Bukhari and Imam Muslim, but if a hadith appears only once, even if it is in one of their compilations, a contradictory hadith will be given greater authority if it appears with greater frequency.

There are also a number of secondary sources of Shari’a.  Ijtihad (“effort” which comes from the same root word “to struggle” that jihad comes from) is the effort of early Islamic jurists to use their own reasoning and judgment to develop the interpretive framework that formed Shari’a in the ninth and tenth centuries.  Most scholars agree that legal precedents were conclusively established between the tenth and twelfth centuries.  Ijtihad was permitted up until the end of the twelfth century, at which point a consensus had developed among scholars that it should be disallowed, and major areas of religious law considered settled by that time, though there is no actual textual prohibition against its continued practice.

Ijma, or consensus, is another secondary source of Shari’a.  This is based on the hadith of Muhammad that “My ummah will never agree upon an error,” where ummah means the community of believers.  However, there is a great difference of opinion as to who the “community” is that is referred to in the hadith.  Different schools of jurisprudence define this community to refer to the first generations of Muslims, the first three generations, the community of Muslim jurists and scholars, just scholars, or the entire Muslim community, including laymen.  So you can imagine the different schools of jurisprudence will accept different ijma as binding.

Qiyas, or analogy, the third secondary source of Shari’a, is the legal principle in which a logical conclusion is deduced from a law set out in the Qur’an, Sunnah or ijma.  An example of a legal injunction derived through qiyas would be where verses of the Qur'an forbid the taking of khamr, thought to be a kind of wine, and qiyas has expanded the prohibition to the use of marijuana and other intoxicants as well.

Confused yet?  Well, numerous as the sources of Shari’a may be, the typical man on the street, who may not be able to read and might not have completed a formal education, will not understand it as like “oh, I’m not supposed to smoke pot because a well-reputed trained jurist applied analogical deduction to a Qur'anic prohibition about wine.”  He will draw his understanding of Shari’a from oral traditions, community discussions, and the opinions of local scholars and judges whom he respects.  Shari’a is, to him, what his imam and other learned men tell him it means.

So who are these learned men?  Specially trained Islamic jurists expand and elaborate on and interpret Shari’a (the sources set out above) and make rulings (fatwa) on legal questions that come before them to be decided based on Islamic law.  They use fiqh (Islamic jurisprudence), which is the tradition of jurisprudence of human understanding of Shari’a, or how it has been interpreted over the centuries to deal with the daily lives of believers (moral and social problems).  Fiqh, because it represents human understanding and not divine revelation, and is not therefore infallible, makes up part of Islamic law, but is not itself technically Shari’a.

Islamic jurists are divided among a number of schools of fiqh, which accept different hadith and give different authority to qiyas when applying Shari’a to modern problems. Since, as described above, these (hadith and qiyas) are fundamental to determining the content of Shari’a, you can see how definitive the school of jurisprudence would be to how the practical legal interpretation of Islamic law will shake out.

The schools of fiqh (Islamic jurisprudence) are also split among Sunni and Shi’a branches of Islam.  The Sunni schools are Hanbali (Saudi Arabia), Hanafi (Turkey, Balkans, Central Asia, India, China, Egypt), Maliki (North and West Africa, Persian Gulf), Shafi’i (Indonesia, Malaysia, Egypt, East Africa, Yemen, Somalia, southern India), and Zahiri (minorities in Morocco and Pakistan). The Shi’a schools are Ja’fari (Iran, Iraq, Lebanon, Azerbaijan, Bahrain, etc.), Zaydi, and Ibadi (Oman).

So the content of Shari’a is already subject to the same difficulties affecting religious texts compiled by dozens of authors over centuries.  The sayings and traditions of the Prophet are then weighed against the text of the Qur’an to separate out contradictory hadith.  The Sunnah is then filtered through the system of ranking hadith by frequency of occurrence and reputation of the compilation in which it appears.  Various schools of jurisprudence (which do not conform strictly to modern national or ethnic boundaries) accept some hadith and omit others, and give some greater or lesser weight than other schools.  Some schools give greater weight to opinions reached through the reasoning of early jurists, by consensus, or conclusions drawn through analogical reasoning (allowing for easier application to modern day situation).  The different schools of jurisprudence each have their own traditions of interpreting Shari’a to set out the rules for the daily lives of their communities of believers. 

Aaaand, then local imams and guys on the corner who have had a few years of school who may or may not be actual legal scholars re-interpret the interpretations of the trained jurists for their neighbors who then tell the Pew Research Center that they want Shari’a to be the official law of the land.  When Bill Maher claims to be able to tell us what this means, I promise you, he is full of it.

I am sorry Brittany Maynard can’t die at home in California, but I am glad we can welcome her here in Oregon

In her viral video, Brittany Maynard explains why she has scheduled her death.  Diagnosed with an aggressive form of brain cancer on New Year’s Day, she was originally given up to possibly 10 years to live.  As she notes, for a 29 year old, this was still like being told you’re going to die tomorrow.  In April, after experiencing increasing headaches and painful seizures, doctors upgraded her status to stage 4 glioblastoma and estimated she had only six months left.  Learning her death would be horrible and painful, she and her family moved from California to Oregon, which provides the option for terminally ill patients to die with dignity.  She has now met the statutory requirements to obtain the medication that will allow her to die peacefully, when the pain of her illness becomes too great, on her own terms.  She and her husband both describe the relief they feel knowing that the choice of when and how Brittany will die is now in her hands and her mom is glad her only child can remain the intelligent, autonomous person she has always been.  

“I don’t look at it every day,” Ms. Maynard says of the medication she keeps in two prescription bottles in a zippered purse.  In fact, as of the latest report, fewer than 65% of the patients who are prescribed the medication have actually chosen to take it, but having the choice preserves for these patients some of the power and autonomy that terminal illness and prolonged immersion with the healthcare system can otherwise drain away.  

In recognition of the fact that many people diagnosed with terminal illness across the country will not have the resources and support system to do what she did and move to a state with death with dignity laws, Brittany is working with Compassion & Choices to tell her story to spread awareness and raise funds in the hopes of prompting legislative change in other states.  Even though I personally think it is such a remarkable act of sacrifice to invite an often-hostile public into such a private time in her life, so that less judgmental minds might be opened, I am still sorry she could not die with dignity at home in San Francisco.  I am sorry she had to uproot and move away from so much that is familiar and loved and come to what will be a chilly Northwestern fall in order to pass away peacefully as she wants to, and as my state (now her state too) says she can.  I am glad that Oregon could welcome her and her family, that we could be her home away from home for this purpose, but I also wish (in all possible ways) that she did not need us at all.

Oregon voters first approved Oregon’s Death with Dignity Act as Measure 16 on November 8, 1994.  I was 13, well before I had any engagement with politics, and even I remember that the vote was incredibly close (51.3% for and 48.7% against) and incredibly controversial in the state.  I am from a conservative area of the state geographically (woo, District 2!) with a concentrated Christian presence that makes up in fervor what it lacks in population density.  This means that religiously controversial ballot measures get heavy opposition locally in op-eds and airwaves, but often pass when they carry the more heavily-populated, and also more liberal-leaning population centers throughout the Willamette Valley (Portland, Eugene, etc.).

The voters were ahead of the legislators on this one, though, and it took three more years to get the law enacted.  The legislature even sent it back to the voters as another ballot measure, Measure 51 in November of 1997, which would have repealed Measure 16, to be like “hey, are you guys sure you really want to do this?” Measure 51 failed by a 10 point margin so yeah, Oregon voters were sure.  This kicked off about a decade of legal and legislative attacks on the law, which seem to have cemented it in Oregon lore as a point of pride.  We are one of only five states in the country that allow death with dignity and we were the first.  The more politicians from outside try to take it away, the more Oregonians rally around it as our own. 

 

After the years of legal and legislative wrangling following the passage of Measure 16, on October 27, 1997, Oregon became the first state to allow “physician-assisted suicide,” which is what we in Central and Eastern Oregon called it at the time – and which I now realize is politically charged and somewhat of a misnomer.   

The term “physician-assisted suicide” brings Dr. Kevorkian immediately to mind, but what we have in Oregon is significantly different than the way he brought about the deaths of 130 of his patients.  Kevorkian would hook his patients up to a machine that delivered a deadly dose of intravenous chemicals, or a gas mask filled with carbon monoxide.  The patient then pushed a button that would start the machine and end the patient’s life.  At the time, Kevorkian was practicing without a medical license, which had already been revoked by the state of Michigan. 

In Oregon, for one thing, the doctors involved have to have their licenses, but I’ll get to the statutory requirements in a minute.  The basic difference is that there are no scary machines with terrifying names (Kevorkian named the IV machine the Thanatron and the gas machine the Mercitron).  The patient is written a prescription for pills, which she, her physician, or an identified agent of the patient can fill at a pharmacy.  She can then take the pills (or choose not take them) on a day and time of her choosing, in her own home, surrounded by people who love her.  The pills produce a painless death in which the patient essentially goes to sleep and her breathing and heart stop.

I say that the adjective “physician-assisted” is perhaps a misnomer because although the attending physician writes the prescription, the patient herself decides if and when to take it.  The doctor is not standing over her bedside “assisting” her in flipping a switch.  Once the doctor has met the statutory requirements, her presence may not even be needed again until it is time to sign the death certificate.

What are the statutory requirements you might wonder?  How do we make sure that family members and caretakers worn down by medical expenses don’t pressure patients into the suicide option?  How do we ensure that depressed or mentally ill patients don’t make decisions to end their lives based on a negatively skewed view of their situation?

Under the Act, two doctors (the patient’s attending physician and a consulting physician with a specialty in the patient’s disease) must agree that the patient has an incurable and irreversible disease which will produce death within six months.  The patient must be, in the opinion of a court or in the opinion of the patient's attending physician or consulting physician, psychiatrist or psychologist, “capable” of making and communicating health care decisions to health care providers.  The patient must make an informed decision based on a number of factors:

(a) His or her medical diagnosis;

(b) His or her prognosis;

(c) The potential risks associated with taking the medication to be prescribed;

(d) The probable result of taking the medication to be prescribed; and

(e) The feasible alternatives, including, but not limited to, comfort care, hospice care and pain control.

While the attending physician must advise the patient of these factors to inform her decision, the consulting physician must confirm that the patient has been so advised, and that her decision is therefore an “informed decision” under the statute.  There are numerous safeguards built into the process, requiring objective witnesses and the possibility of mandated counseling if either physician suspects depression, to guarantee that the patient is capable and making a voluntary, informed, and unimpaired decision.

There are also built in waiting periods to allow the patient time to consider her decision.  The patient must request the medication orally and in writing, and then must reiterate the oral request to her physician at least fifteen days after the first oral request.  There must be at least fifteen days between the patient’s first oral request and the writing of the prescription, and there must be at least 48 hours between the patient’s written request and the writing of the prescription.

No one can willynilly move into Oregon one day to take advantage of the law the next.  You have to be able to demonstrate Oregon residency in order to be a qualified patient under the Act.  Some of the factors demonstrating residency include possession of an Oregon driver’s license, registration to vote, evidence that the patient owns or leases property in Oregon, or filing of an Oregon tax return for the most recent year.  For a patient with less than six months to live, this level of expense and bureaucracy will not be easy to pull off.  This is why Brittany Maynard has chosen to advocate for broader availability of these laws.

Many of the early fears voiced about Oregon’s law have proven unfounded.  The safeguards have proven effective in making sure that patients aren’t coerced into taking the medication.  As I mentioned earlier, many of the people who are prescribed the medication decide not to take it, just having the option there gives them peace and relief and a sense of some control over their fate.  I remember back in the 1990s there was also a concern that there would be thousands of Brittany Maynards moving into town from all over the country to die under the law.  This has also not proven to be true.  In the nearly 17 years since the law went into effect, only 1,173 people have been prescribed the medication and only 752 people have chosen to take it.  That is hardly hoards of suicide-seekers flowing over our borders and rather supports the view that the law works well to ensure that the handful of terminally people who want this choice can get access to it. 

Finally, despite requirements under the law that the patient be informed about all available options, including palliative care and hospice, fears persist, that patients who choose suicide do so because they simply don’t understand these other programs.   This is patently untrue.  In 2012, 97% of patients who made requests under the Oregon Death with Dignity Act were enrolled in a hospice program.  A 2010 National Journal/Regence Foundation poll found that Oregon residents are generally better informed about end of life options than the general population across the country.  In Oregon, 94% of residents knew about hospice care and 32% were aware of palliative care, as opposed to 86% and 24% knowledge of these terms among the national population respectively.

However, these programs, while they have their benefits and can extend the time a patient can spend with family members, also have their downsides which only a terminally ill patient can weigh.  Even aggressive pain management, cannot keep ahead of all of a patient’s pain, and can include side effects such as hallucinations, night terrors, sweats, incontinence, and a loss of lucidity.  The patient is at least occasionally self-aware enough to experience a loss of dignity and autonomy, which can cause anxiety and depression.  Hospice programs are well-aware of these emotional side effects and often have social workers and therapists available for the patient and family members to work through depression. 

My family and my friend’s family lost a loved one this year after rounds of palliative care that balanced the wide, dark void of morphine-induced anxiety with the heavy sleep it would finally bring.  Hospice nurses said chocolate ice cream for breakfast and dinner was fine because “why not give her whatever she wants?” and who knew chocolate ice cream could seem bleak or sad?  I cannot say enough wonderful things about hospice, the nurses and social worker were a Godsend for us but in the end they had the cog-in-a-great-wheel feeling of the little Lego construction workers with set plastic hands that fit all kinds of tools that ratchet into the various widgets of the machine of death but do not change its course.  I can see how these options might fall short for some patients.  I can believe that for people who do not have strong religious prohibitions against it, being able to control exactly when and how you die could bring some peace.

As I mentioned, most Oregon Death with Dignity patients are also in hospice care.  Many, like Brittany Maynard, are also taking other medication to control their pain and illness.  There is a risk, though, that someone could wait too long to make a DWDA request.  Once the patient has progressed, either through psychological conditions, side effects of medication, from illness, or weakness from lack of food, to the point at which she is no longer capable of making an informed decision about her own care, she is no longer a qualified patient under the law.  Moreover, a loss of motor control caused by pain medication could make it impossible for a patient to take advantage of the Death with Dignity Act because the patient must self-administer medication prescribed under law. 

Maybe this is why Ms. Maynard has chosen a date for her death.  She has picked November 1^st, only a couple weeks away, to end her life.  This day falls just after her husband’s birthday (and a week before the 20 year anniversary of the passage of Measure 16).  It has unnerved some people that she has picked a specific day, like maybe she will feel locked into it now that she has it on her calendar and the eyes of the world (and the media) are on her.  But I suspect since she got her 6 month prognosis on April 2, Ms. Maynard is already on borrowed time, as the symptoms of her cancer will have progressed.  My hope for her is that the medicine that has been prescribed for her under Oregon’s law does what it has done for other Oregon residents before her: merely give her the option to choose whether to take it or not, and when.