This is what Peter Rasmussen, medical oncologist, did on the afternoon of April 9: He drove to the home of Randy Marcus, the son of one of his patients. He went to an upstairs bedroom, where 71-year-old Barbara Houck--the patient--lay in a hospital bed, suffering from late-stage ALS, a debilitating, terminal disease that affects the central nervous system. He opened 90 secobarbital pills--a lethal dose--and poured the fine white powder into a bowl of chocolate pudding. He gave the mixture to two of Barbara's sons--Randy, and her youngest, Bryan Houck. Then he sat, quietly, while Randy helped spoon the pudding into his mother's mouth, and Bryan offered small sips of water to wash it down.
A few minutes later, Barbara joked that "there wasn't anything to watch on TV tonight, anyway," then seemed, Randy says, to "just relax and go to sleep." He remembers that his mother's eyes fluttered under her lids for a few minutes, before she grew still. Barbara's body would hold on for 12 more hours, and Bryan sat with her through all of them--holding her hand, watching the clock, counting her heartbeats. She finally slipped away at 4:10 a.m. the next day.
Barbara Houck is one of approximately 30 Oregonians who have used the state's one-of-a-kind Death With Dignity Act to commit suicide with the assistance of a physician. The law took effect on Oct. 27, 1997, after surviving two statewide referendums and protracted court challenges. It allows doctors to prescribe--but not administer--a lethal dose of drugs to patients who are determined to have less than six months to live, are deemed mentally competent, and who request the procedure themselves in front of two witnesses.
Now, though, the Death With Dignity Act is fighting a new battle: Last week in Congress, the House of Representatives passed the Pain Relief Promotion Act--a bill that would overrule an individual state's right to legalize euthanasia, and thus negate the Oregon law. The vote was 271-156. Senate leaders are confident they have the votes to pass the bill as well.
Arguing in support of the bill, Rep. Charles T. Canady (R-Fla.), one of the sponsors, referred to physicians who assist in suicides as "agents of death." And Rep. Henry J. Hyde (R-Ill.), another supporter, argued that the law allows doctors to "thrust death upon" their patients.
Rasmussen hears these words used to describe members of the medical profession--to describe himself, really--and he barely flinches. He has, by his own admission, assisted on "more than two" suicides in Oregon under the law. (He refuses to name an exact figure.) But he does not pretend that his opponents are wrong when they argue that there are abuses, or at least the possibility for abuses, of this law.
"That potential is always there," he says. "We need to protect against it."
But Rasmussen is not here, in Salem Hospital, between rounds, to speak to the cases that he knows nothing about. He is here to speak to his own--to those patients who have come to him for help not in prolonging their lives, but in ending them. And to the reasons why he has said yes.
Taking a Stance
"One of the things I feel saddest about is that I've spent most of my time here doing a lot of work to enhance the cancer program and I think I've been reasonably successful in those efforts. Yet, I know that people think of me and will always remember me as 'the suicide doctor.' And that makes me sad."
--Peter Rasmussen, Oct. 31, 1999
He is not Jack Kevorkian. This much, Rasmussen makes very clear. It's not that he has personal feelings about the man, but there are significant differences. Kevorkian--a man who has helped more than 130 people commit suicide--has operated outside the law. He has been accused by a coroner of helping one woman die who was not even physically ill. He has been convicted of murder in Michigan.
"It's his passion," Rasmussen says. "I am a doctor, with a practice. This is not what I do. I treat cancer patients."
For the past 20 years, Rasmussen has been a medical oncologist here in Salem, with privileges at Salem Hospital. He sees cancer death all the time.
He grew up in Elmhurst, Ill., one of five children of a structural engineer and a homemaker. He "fell into" medicine, by his own description, after making something of a career of being a student. He chose Oregon for his practice simply because he liked the place--the liberal politics, the outdoorsy lifestyle, the laid-back approach. Now 54, he was married two years ago, to a travel agent named Cindy Brandtjen, who has two children, Gretchen, now 12, and Keith, who is 8. Over the desk in his office, there hangs a small handmade note from Gretchen with hearts and expressions of love. He drives a red Mazda Miata with a hard top to hold his canoe. He thinks, perhaps, that his next car will be electric, for the environmental soundness of it all.
Rasmussen always has been something of an activist, though never one who has landed in jail for a cause. As a student in the 1960s, he marched in parades for Eugene McCarthy. He distributed anti-war leaflets while in medical school at the University of Illinois-Chicago. He has belonged to the American Civil Liberties Union for most of his adult life.
Before he became known for his stance on assisted suicide, Rasmussen says, he had been politically active on two issues here in Oregon: He supported a ban on smoking in public places, and he supported hospice care for terminally ill patients.
His feelings on assisted suicide evolved slowly. The first time a patient approached him and asked for help to end her suffering--almost 10 years before the Oregon law existed--Rasmussen fought an inner debate, then wrote her a prescription for sleeping pills. He says now that he cannot remember if the prescription was for enough pills to cause death, but acknowledges that his intent was to help the woman stockpile the pills to use as she saw necessary.
"I think about that first case with some embarrassment," he says. "I'm sure I would not do that again. That wasn't good practice."
His feelings crystallized when he served on the hospital's ethics board, and he and his colleagues had lengthy debates over whether an individual could actually be sane and still want to commit suicide. He decided the answer was yes. Many of his colleagues took the opposite stance. Many still do.
"Well, Peter Rasmussen is an enthusiast, he's a zealot," says Gregory Hamilton, an Oregon psychiatrist and the president of Physicians for Compassionate Care, an organization formed in opposition to the Oregon law. "Frankly, I don't think these people know very well what to do--how to respond to an assisted suicide request. You have to treat it."
Rasmussen disagrees. He believes that a terminal patient can soundly, thoughtfully, decide that she would rather control her own death than be controlled by it. Which, he says, is the primary reason he has seen patients request assisted suicide--not because of fear of the pain, but because of fear of living out their final days in a state that horrifies them.
"I think it's important to note that most patients with terminal cancer, for example, can have their pain controlled and be awake and alert," he says. "But that's not always the case, with some cancers and some other illnesses. For those people, their choice is either unbearable pain, or to live as a zombie. And that is not acceptable to them."
Barbara Houck was one of those people.
One Woman's Choice
It was January when Randy Marcus found out that his mother--his best friend--was dying. He had been on a trip to Wyoming to pick up his youngest daughter and her husband and move them back to Oregon. Terrible weather turned the return drive into a four-day ordeal, and he was relieved to get home. Until he saw his mother, and she told him the news.
Barbara had undergone hip surgery several weeks before, and had been suffering through physical rehabilitation. But after progressing to the point where she could walk halfway up the staircase in her condo unassisted, she began to regress. Suddenly, she couldn't make it up a stair. Something else was wrong.
That "something" turned out to be ALS, commonly known as Lou Gehrig's disease, an illness that attacks the central nervous system and leads inevitably to paralysis and death. And Barbara knew, right away, that she wasn't going to let herself die in that manner.
"In the end, you have no movement--only eye movement, but your mind is as sharp as ever," says Bryan, who researched the disease on the Internet as soon as Randy shared the news with him. "You're captured in your body. It's like a prison. Mom didn't want that. She said it was her worst fear."
Barbara Houck always had been a practical, no-nonsense woman. Raised in near-poverty, she responded to the need for a pair of black shoes for a social function by painting the only shoes she owned--white ones--with black paint. She always told her four sons--Dennis, Larry, Randy and Bryan--not to whine about something, but to fix it. Solve it. Figure out a plan. After divorcing her first husband, she remarried, to a man named Ron Houck, who adopted Bryan, the youngest of the four boys, as his own. She also added two stepsons to her brood at the time. One of them, Jerry, "always gave everyone a hard time," according to Randy. Everyone but Barbara, that is. "She knew how to stand up to him," Randy says. "She knew how to stand up to anyone."
It came as no surprise to any of her children, then, when Barbara started talking about assisted suicide almost immediately after her diagnosis. And her talk grew louder and louder as the disease progressed. By the time the family decided to move Barbara into Randy's five-bedroom home, where she could get better round-the-clock care, it took four firefighters and a hoist to get her into an upstairs bedroom. She could sit up in her bed and move her arms, but couldn't walk or roll herself over. It took six to eight hours every time--and the assistance of family members--for her to get on a bedpan and have a bowel movement.
"I used to bring her pies," Bryan says. "That's the only thing she could enjoy anymore--eating. She had a sense of taste. So I'd go and bring her things from the bakery."
Carrot cake was her favorite. Carrot cake, and lemon meringue.
Deciding to Assist
Rasmussen first met Barbara when he came to the house on Feb. 21. Randy and Bryan were elated to meet him--Barbara's family doctor had refused to assist in her suicide, a decision not unusual among Oregon physicians despite the law. Only after much prodding had he provided a referral to Rasmussen, who was known by that time for agreeing to aid patients not his own, if they were referred by their own physician, and that physician would certify the individual's terminal status.
In his notes from that day, Rasmussen stated that Barbara did, indeed, appear to have a progressive neurological disorder, but that he was not convinced at the time that she had less than six months to live. He warned her, then, that she might fall into one of the law's loopholes. She might lose her ability to swallow--and thus ingest the fatal dose on her own, as required--before she reached the six-month cutoff. He talked to her about her other options--declining food or water, or medications--none of which were appealing. He gave her practical advice on how to lessen the itching of her skin. He promised to help get Barbara in hospice care, with an emphasis on lessening her suffering, rather than prolonging her life. He promised to keep in contact.
"I remember that she was very clear about what she wanted," he says. "There was no doubt in my mind about that."
Rasmussen returned on March 28, after having numerous phone conversations with Barbara ("a crash course in getting to know her," he calls it). Her condition had deteriorated significantly. She could move only her left hand, her eyes, and--significantly--her throat, to swallow. He agreed, as attending physician, to certify that she had less than six months to live. Barbara's family doctor served as the required consulting physician, seconding that diagnosis.
Both doctors deemed Barbara to be mentally competent to make her own decision in the matter, thus nullifying the need, by law, for a psychiatric evaluation, but Rasmussen likes that extra safeguard, and so Barbara met with a psychiatrist on April 7. Several family members attended.
"The rest of the family, those that were at the meeting--we were under a lot of stress, and we were showing signs of that stress," Randy says. "Mom was saner than anybody."
While none of Barbara's family members tried to prevent her decision--and most, like Randy and Bryan, supported it wholeheartedly--it was not easy for everyone to accept. Elena Marcus, the wife of Barbara's oldest son Dennis, has reservations for religious reasons. Larry, the second-oldest son, also disagreed somewhat with the decision, though he did not express that to his mother, according to Bryan, and to this day has not wanted to explain his feelings to his brothers. Even Bryan, who says he would do the same thing if he were in a similar situation, had pangs on the day it was to take place.
"I had to be strong for her," Bryan says. "I had to leave my selfishness aside. I couldn't think: 'I'm not going to be able to pick up the phone and call her. I'm not going to be able to give her a hug.' That wasn't important. She earned that respect, to have us be tough for her and make this be as easy as possible for her."
Barbara chose April 9 as the day she would end her life. The paperwork was finished, the state-required waiting period complete. Her granddaughter Melissa--Randy's oldest daughter and Barbara's primary caretaker--had just given birth to the baby boy Barbara had so desperately wanted to see.
It was an awkward, bittersweet day. Throughout the morning, family members and friends traipsed through the house, paying their respects. Elena may not have agreed with Barbara's decision, but she came, did Barbara's hair and her nails. Made her feel beautiful one last time.
Rasmussen arrived late in the afternoon. The chosen time was 4:30. Rasmussen still isn't certain, really, what kind of role he should play at these moments, once he hands over the medication and completes his part in the process.
"Sometimes," he says, "I'm there to answer questions. Other times, there's an ongoing dialogue or discussion."
In Barbara's case, the brothers turned to reminiscing, telling stories about their mother and their past. Rasmussen stayed for two hours--Barbara's death, at 12 hours, took far longer than usual, though she never regained consciousness--then left at the family's urging. He went to the hospital, checked on his patients. He stopped back to look in on Barbara one more time. Then he went home to his family. For this day, his work was done.
CAPTION: Peter Rasmussen treats cancer patients, but he says, "I know that people think of me and will always remember me as 'the suicide doctor.' And that makes me sad."
CAPTION: Before Barbara Houck died, she could move only her left hand, her eyes and her throat. Being imprisoned in her body was her "worst fear," says son Bryan.
CAPTION: Randy Marcus, Barbara Houck's son, supported her decision wholeheartedly.