How do we die? With drugs, oblivious, in a basement, frozen nobly on a mountain top, screaming in a car crash, or traditionally in a bed surrounded by our family and children, croaking out our last wishes? Or in hospital, where there are tubes and bleeps, where we are monitored, fed intravenously and kept alive till the last moment? Most of us shudder, try to think about something else and admit that we are with Woody Allen when he said he didn't fear death, he just didn't want to be there when it happened.
But there are places where they have tried to bring death more under our control. Holland has an excellent assisted suicide plan and was the first country to adopt one. Less liberal ones exist in Belgium, Switzerland and Germany, which all have some way for the clued-up and determined to end their own lives. I had always thought it wouldn't work in Britain because we're too inefficient - if we can't even ensure that a sad old woman gets her shitty sheets changed, how can we be sure she has really chosen to die? - and that it wouldn't work in the US because it was so commercial. But Oregon is different.
When the Pacific north-west state passed legislation in 1994 - finally implemented in 1997 - to make physician-assisted suicide legal, there were all manner of dire predictions: the old and tiresome, the poor and the marginalised would be wiped out; people in other states would pour in, demanding to be helped out of this world; the state's biggest city, Portland, would become the death city of America. There were nightmare memories of Jack Kevorkian, a maverick in Michigan who helped 130 people to kill themselves with no safeguards to speak of and was known as Doctor Death: he only came out of prison last year. Most importantly, there were fears that no one would bother with palliative care any more, because patients could simply be discontinued.
None of this has happened, although the British Medical Journal last week reported that doctors in Oregon prescribing lethal doses of barbiturates may on three occasions have administered them to people with clinical depression. In cases where there is any doubt, patients should be referred to a psychiatrist, just one of many safeguards that were built into the legislation: a request must be made twice, two weeks apart, to prevent someone in a fit of gloom signing something they might later regret, and the signature has to be witnessed by two people, only one of whom may be a relative, so no two avaricious offspring can shunt mom into her grave.
A doctor also has to certify that the patient has not long to live and is of sound mind, which includes not being clinically depressed; the doctor can write a prescription for the lethal dose, but the patient, or someone chosen by the patient, must get it from the pharmacist - and any pharmacist who has moral objections can refuse to supply it.
A flood of suicidal incomers has been prevented - if there ever was a threat of them - by the fact that only residents can apply for physician assisted suicide (PAS). If someone arrives, says that they want to live in Oregon and please can they take advantage of PAS, there has to be extensive proof - house deeds, car licence and so on - that they really do want to live there as well as die. This can have sad consequences. I talked to a man who had lived in the state all his life, as had his wife. When he retired, they sold their house and went to live in Hawaii, but after only two years she developed terminal cancer and hoped she need not suffer to the end. But they were no longer Oregon residents and didn't qualify for PAS.
Since the introduction of the Death With Dignity Act in 1997, remarkably few people have actually "gone the Oregon way" - only 431 (one death in 1,000). And only one in 10 of those who ask for a prescription actually end up using it - they feel secure knowing they have it as a last resort. Far greater numbers have an advance directive, setting out the treatments they don't want to have, even to prolong life.
Of course, PAS is not the only way to go. There's an organisation that seems the equivalent to our Exit called the Hemlock Society that goes in for, in the scornful words of one nurse, "booze and a plastic bag". A surprising number of patients simply stop eating and drinking - not a pleasant way to go, but apparently one that upsets families and nurses less than taking a lethal dose. I talked to a diabetic who casually mentioned a cousin who had deliberately overdosed on insulin. And on my first morning in Oregon my middle-aged waitress asked me why I was there, and, when I told her, said approvingly that her sister had taken her own life after six years in pain: "When she'd done it her face looked like she was 20." But this was before the change in the law, so how had she done it? "She shot herself," she said cheerfully. "There wasn't more than a little blood."
The last time a euthanasia bill came before our parliament, much was made by Baronesses Knight and Finlay of the fact that allowing any form of assisted death had impacted badly on palliative care in Oregon. This was firmly refuted by the Oregon Hospice Association's then chief executive, Ann Jackson, who pointed out that hospice care in the state had doubled since the Act, that Oregon was rated the second best state in the US for it, and that the only measure on which they did not score highly was palliative care in hospitals - not surprising, since hospice care in Oregon follows the patient and 95% of it is done at home, where people prefer to die. They see their work as a British invention, revere the memory of Cicely Saunders and use "hospice" as a synonym for palliative care, not just for a care home.
A survey of Oregon doctors also showed that, since PAS, they have actually taken more care with areas such as pain relief - presumably in the hope of making their patients content to stay alive. Of patients who opt for assisted suicide, 86% are hospice patients, and the hospices, originally opposed to it, now mostly accept and help with it, though any nurse with conscientious objections can give the patient a "warm hand transfer" to another. They also have foster care for some older, sicker people - a useful idea for families that can't cope or aren't around.
Many hospice people, and their volunteers, see PAS as a friendly, reasonable way to end a life, better than being strung up to tubes and monitors in intensive care. Some of the volunteers create colourful quilts, to make things a bit less bleak for those who are in hospital. George Eighmey, of Compassion and Choice, the body that originally fought for the law and now helps people towards decisions in dying, told me of a woman who had had a double mastectomy and made a display of her three or four dozen bras on a clothesline, and of a man who had had bladder trouble who filled a row of potties with petunias and pansies - all part of trying to make illness and even death more homely, more bearable.
The legislation is extremely tightly drawn, and efforts to prove it unconstitutional have so far failed. Some argue that all this could only happen in Oregon: California and Hawaii tried and didn't manage to introduce PAS, though Washington state is toying with the idea at the moment. Oregon, and Oregonians, are certainly cussed about not being told what to do by Washington DC or anyone else. They pride themselves on being the only state that refuses to allow any private building on the seashore that might keep people from getting to the beach; they refused to assure Homeland Security, the federal terrorist-chasers, that their local police force would cooperate with them; they coped with their litter by insisting on a return charge payable on bottles, and have the first oscillating water column for producing wave energy off the west coast. (It is also a state in which skateboarding is a legal form of transport on roads.) "These are the rugged individualists who conquered the west," says Dr Linda Ganzini, who has done extensive research on assisted dying. Their conviction that people should be able to choose how they die is part of their insistence on their own autonomy - and in patient autonomy, as opposed to meekly doing what the doctor says.
Far from being the sad and disadvantaged, the poor and the unwanted who are shuffled off into the hereafter, it is mostly the strong-minded and competent who achieve the death they have chosen. Patients don't always choose PAS for the most obvious reason, intractable pain: men can't bear the collapse of normal bodily functions and the fact that other people have to cope with them; women are more likely to despair of lives in which all the things that gave them any joy or satisfaction are now beyond them.
So, is it all dead easy in Oregon? Not really. The very safeguards in the rules also serve to exclude some who might dearly love to have access to a planned and dignified death. It is the educated, the competent, those with a decent relationship with a doctor - which, in practice, usually means those with a decent relationship with health insurance - who are likely to seek it. The very poor have Medicaid, (which doesn't pay too well so not all doctors welcome it), those in employment or pensioned retirement have good insurance, and the elderly have Medicare. But it is very difficult for those who are hard up, in erratic employment but not actually on the streets - those who make up the 17% of those who have no insurance at all - to raise the required cash to form a satisfactory relationship with the doctor, who has to certify the patient has less than six months to go. This often excludes those with Aids or MS or, of course, Alzheimer's. Of the European countries that have assisted death, only Holland does not require death to be more or less imminent. Yet if you are bleakly in pain and not going to die pretty soon anyway, you might ache even more for an ending to it all.
The hospitals that are in any sense religious won't have anything to do with it, and neither will federal hospitals - their personnel are told that if they even tell patients how they might access PAS, they'll be fired - though a few supporters of the legislation managed to ensure that it's only on hospital premises that they aren't to tell patients about it (it's OK, apparently, to slip them the word in the Starbucks across the street). The Oregon Health and Science University will take on such patients, the Kaiser Permanente HMOs - they are like mini health services - are not opposed, but any idea that it's a breeze in Portland, let alone in remoter areas, to demand an easy death is definitely wide of the mark.
There is still virulent opposition. Many religious people are unalterably opposed (though there hasn't been any of the violence associated with anti-abortionists). Questions of life and death were brought into fierce public debate nationwide in 1998 by the case of Terri Schiavo, the Florida woman who had been kept alive in a coma for years following a heart attack. Her husband wanted her artificial feeding and breathing withdrawn, but her mother thought that even if she were never to regain consciousness, her life had value - and many agreed. After a prolonged legal battle, her feeding tube was withdrawn in 2005, leading to her death.
The national organisation of the disabled, Not Dead Yet, thinks any suggestion that lives should be deliberately ended devalues the lives of the disabled, that the law "deprives the disabled of the benefit of suicide prevention". Many doctors, too, are deeply uncomfortable with the whole idea; their instinct is to keep the patient alive, come what may. Ganzini says that "physicians feel uncomfortable because it is not what they know how to do and feel the patient is rejecting them, saying their care isn't good enough". Quite a few will have nothing to do with it, which makes it even harder for the less competent or poorer patients to find the right help.
On the Sunday I was in Portland, a friend took me to a barbecue, under towering, dark trees in warm autumn sunshine. There I met two or three people who had had some contact with PAS. They spoke sadly of dying but did not question the decisions of the deceased. One gentle woman who worked as a volunteer with patients said she had nothing against assisted suicide, but didn't think that was what we ought to be worrying about. What concerned her far more was the people who never, under their system, got good health care, who were old or sad or desperately poor and had no one to care for them; that, she said, was where we should be putting our efforts.
She's probably right, but Oregon at least shows the way forward for dealing with the problem that is not brought about by too little health care, but almost by too much - by our ability to keep people alive long after they would once have served their term. The Oregon way of dealing with death is principled, comforting and a model of how things might be, once we face up to rethinking the end of life as we have rethought the beginning.
'It was the most peaceful, loving moment of my life'
One woman's account of her mother's assisted suicide
Some families have warm and precious memories of such a death. I spoke to Julie Macurchie, whose mother, Margaret Sutherland, chose to die this way at the age of 68. Sutherland was a feisty woman; divorced after 40 years, she made a life of her own. She discovered new friends, joined boards and became a volunteer in a local hospice. In 1985 she was diagnosed with lung cancer, having smoked for years. It appeared to be cured, but returned in 2000 and by September of that year her condition was diagnosed as terminal.
"There was no pretending," her daughter remembers. "She was practical and pragmatic, as she had taught us to be. She was not weepy or depressed, and did as much as she could, but in December she woke up and couldn't get out of bed for pain." For three weeks they tried to get it under control in hospital and she had a morphine pump, but she still couldn't get out of bed. "We brought her home and she said, 'I'm going to use Oregon's law.'"
There was the 15-day waiting period; her daughter got the medication. "The morning she died there were five of us there; she was in her lovely big bed by the window, looking out on the river. She wanted a poem by Anne Dillard, and the 23rd psalm. We weren't a religious family but we found a Bible and began to read, then she said, 'No, not that version - I want the King James version,' and we managed to find that.
"She drank the medication with us all around her. She might have died alone in the dark but she was looking at all her children. It was the most peaceful loving moment of my life. I feel so lucky and fulfilled that I was able to do that for her. In five minutes she was unconscious and in 15 minutes she'd gone."
