Oregon's systematic design for universal access to health care, known as the Oregon Basic Health Services Act, has provoked heated debate over its rationale, plan and process. It is a novel attempt to address inequities in the distribution of health care for those below the federal poverty level. Its controversial nature compels more informed discussion to guide further analysis. Accordingly, this report is primarily descriptive, aiming to provide a clear synopsis of the Oregon project's history, complex methodology, (...) and strengths and weaknesses. (shrink)

In using quality of life as a guide to rationing health services, Oregon laid itself open to charges of bias against the disabled—charges that cannot be dismissed out of hand.

The Oregon Health Division's report on assisted suicide under the state's new legislation does not provide enough data to support its reassuring conclusions. Especially glaring is the lack of data on the palliative care offered to patients who requested assisted suicide, on their financial situation, and on their emotional state.

The Oregon Health Plan gained national attention by changing the focus of health care from who is covered to what is covered. This change was facilitated by insurance reforms in the areas of small market, employer mandates, high risk pooling and Medicaid. Most controversial of the reforms is the use by the legislature of a prioritized list of health services to determine benefit levels for the insurance programs. Significant debate has occured over whether the use of such a list (...) is rationing or reasoning. The Oregon Health Plan represents a thoughtful and deliberate blending of fact with public value for the purpose of responsible health policy. It is that unique blending of public values developed through community participation with fact that focused the attention of the world on Oregon. Keywords: community participation, employer mandates, health care reform, prioritization, rationing, small market insurance reform CiteULike Connotea Del.icio.us What's this? (shrink)

Prior to passage of the Oregon Death with Dignity Act, opponents of assistance in dying argued that legalization would have serious harmful consequences. Specifically, they argued that the quality and availability of palliative care would decline, that the harms of legalization would affect certain vulnerable groups disproportionately, that legal assisted dying could not be confined to the competent terminally ill who voluntarily request assistance, and that the practice would result in frequent abuses. Data from Oregon's decade-long experience decisively (...) refute the first three predictions. As to abuses, the record is not quite as clear, but if an appropriate framework for analysis is utilized, the most reasonable conclusion is that the risks of abuse do not outweigh the benefits of legalization. To the extent projected harmful consequences are relevant to the debate over legalization, Oregon's experience argues in favor of legalization of assistance in dying. (shrink)

When one considers the protracted and continuing struggle of the citizens of Oregon to include physician-assisted suicide among the panoply of measures available to dying patients and the physicians who care for them, the depth and breadth of the issue becomes inescapable. The potential intractability of the dispute is illustrated by the very fact, noted in the preceding parenthetical phrase, that consensus eludes us on even the most basic of semantic points—how we are to most aptly characterize the conduct (...) in question? The case featured in this issue's The Caduceus in Court must be examined as the latest battle in a long war of attrition waged by opponents of physician-assisted suicide against the Oregon Death with Dignity Act. After briefly reviewing that history, I will then consider the details of Oregon v. Ashcroft and the implications of the litigation not only for the care of dying patients but also for the regulation of medical practice in the United States and, more broadly still, the search for resolution of serious medical disputes in a democratic society. (shrink)

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, but it is mostly (...) hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

Slippery slope argumentation features prominently in debates over assisted suicide. The jurisdiction of Oregon features prominently too, especially as regards parliamentary scrutiny of assisted suicide proposals. This paper examines Oregon’s public data (including certain official pronouncements) on assisted suicide in light of the two basic versions of the slippery slope argument, the empirical and moral-logical versions. Oregon’s data evidences some normatively interesting shifts in its assisted suicide practice which in turn prompts consideration of two elements of moral-logical (...) slippage that are not widely discussed. One is slippage from an initial autonomy-based public justification for assisted suicide which does not include burden-based concerns within its operative account of voluntariness to an evolved public justification that does. The other is an expansion of a terminal illness ground to include chronic illnesses effectively rendered terminal via a refusal of treatment. (shrink)

Since 1998, physician-assisted suicide has been legal in the American state of Oregon. In this paper, I defend Oregon’s physician-assisted suicide (PAS) law against two of the most common objections raised against it. First, I try to show that it is not intrinsically wrong for someone with a terminal disease to kill herself. Second, I try to show that it is not intrinsically wrong for physicians to assist someone with a terminal disease who has reasonable grounds for wanting (...) to kill herself. (shrink)

When terminally ill people are given the option of legally hastening death, they often feel a sense of greater well-being and a desire to live longer. In my explanation of this paradox, a terminally ill person has two selves. The right-to-die empowers the future self to gain control of suffering at the end of life. That makes the present self, who has empathy with the future self, feel a surge in well-being and the desire to live a longer life.

The euthanasia literature typically discusses the difference between “active” and “passive” means of ending a patient’s life. Physician-assisted suicide differs from both active and passive forms of euthanasia insofar as the physician does not administer the means of suicide to the patient. Instead, she merely prescribes and dispenses them to the patient and lets the patient “do the rest” – if and when the patient chooses. One supposed advantage of this process is that it maximizes the patient’s autonomy with respect (...) to both her decision to die and the dying process itself. Still, despite this supposed advantage, Oregon is the only state to have legalized physician-assisted suicide. After summarizing the most important Supreme Court opinions on euthanasia (namely, Cruzan v. Director, Missouri Dep’t of Health; Vacco v. Quill; Washington v. Glucksberg; and Gonzales v. Oregon), this paper argues that while there are no strong ethical reasons against legalizing physician-assisted suicide, there are some very strong policy reasons for keeping it criminal in the other forty-nine states. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Gonzales v. Oregon and the Politics of MedicineRonald A. Lindsay (bio)Throughout 2005, the morbid joke on Capitol Hill was that the twin inevitabilities of "death and taxes" had been replaced by "death politics and taxes." There seemed to be some truth in this observation given the highly publicized intervention by some members of Congress in the Schiavo case and the continuing controversy over government regulation of end-of-life care. (...) The Supreme Court's recent decision in Gonzales v. Oregon (74 U.S.L.W. 4068 (17 January 2006)) has resolved one of the critical issues relating to this controversy by holding that a physician may prescribe controlled substances to provide assistance in dying if such a practice is authorized by state law and not expressly prohibited by federal law. However, other issues remain. In fact, the Court's decision has underscored some of the reasons why there is not only continuing controversy over end-of-life care, but also over other aspects of the practice of medicine. First, it is apparent there is no consensus among health care professionals about the precise boundaries of the legitimate practice of medicine. Second, the regulation of the practice of medicine traverses ill-defined legal territory. In particular, there is significant uncertainty concerning the implications of some regulations as well as the allocation of regulatory authority between and within state and federal governments. This uncertainty leaves substantial room for political maneuvers.Before discussing the politics of medicine, it is worth looking at the regulation of controlled substances in some detail both because this review will provide the necessary background for understanding the ruling in Gonzales v. Oregon and because it will illustrate the uncertainty resulting from multiple sources of regulatory authority.Federal and State Regulation of Controlled SubstancesSince the Pure Food and Drug Act of 1906, the federal government has regulated certain aspects of the distribution and administration of drugs deemed susceptible to abuse. The current primary vehicle for federal regulation is the Comprehensive Drug Abuse Prevention and Control Act, enacted in 1970, of which Title II is known as the Controlled Substances Act (CSA) (21 U.S.C. § 801 et seq.). A [End Page 99] "controlled" substance is just that, a substance that is regulated under the CSA. The CSA classifies controlled substances in five categories or schedules based on their potential for abuse, their accepted medical use, and the risks associated with their use under medical supervision. Schedule I substances have a high potential for abuse and have no currently accepted use in medical treatment. Schedule II-V substances are approved for medical use but are subject to a descending hierarchy of restrictions on their use. To give a lawful prescription for a controlled substance, a physician must be registered with the appropriate federal agency, currently the Drug Enforcement Administration (DEA). Moreover, to be valid, such a prescription must be issued for "a legitimate medical purpose" (21 U.S.C. § 830(b)(3)(A)(ii)).There is little dispute that the primary purposes of the CSA are to control drug abuse and to eliminate illicit trafficking in drugs. In accomplishing these objectives, there is a division of responsibility among various federal agencies, in particular the Department of Health and Human Services and the Department of Justice. Of particular relevance to the controversy in Gonzales v. Oregon is the Attorney General's authority to revoke a physician's registration for prescribing controlled substances if the physician's registration would be inconsistent with the public interest.All 50 states have their own statutes and regulations that address various aspects of the distribution and administration of controlled substances. Most states have adopted versions of the model Uniform Controlled Substances Act, which largely mimics federal law, but several states have placed additional restrictions on a physician's ability to prescribe controlled substances, including time limits on the validity of a prescription and limits on the quantity of a drug that can be prescribed. States are the primary, but by no means the exclusive, source of regulation of medical practice in general. States license physicians, establish boards and agencies to regulate the actions of physicians, and promulgate rules and guidelines to which physicians... (shrink)

Starting January 1, 2017, the Oregon Health Authority (OHA, henceforth) made a sweeping decision that no elective surgery is to be performed for Medicaid recipients who smoke tobacco. The authors of this paper investigate the administrative procedures behind the OHA’s decision, explore some possible ethical arguments for and against the decision, and render our ethical verdict about the ban and our suggestion for the OHA. Meanwhile, since this issue involves the problems of smoking-related addiction, the agent’s autonomy which may (...) be understood in the light of moral freedom and rationality/irrationality, and our society’s perception about obesity and cigarette smoking; the paper engages in a deeper philosophical debate about the problems beyond the legal purview of the ban. (shrink)

With assisted suicide now legally sanctioned, health care professionals in Oregon face the challenge of implementing Oregon's Death with Dignity Act. Physicians, hospice professionals, pharmacists, and other caregivers may find their relationships with patients, families, and fellow professionals changing in unanticipated ways as all learn what it means to make aid in dying openly and compassionately available to patients at the end of life.

Some form of assisted dying (voluntary euthanasia and/or assisted suicide) is lawful in the Netherlands, Belgium, Oregon, and Switzerland. In order to be lawful in these jurisdictions, a valid request must precede the provision of assistance to die. Non-adherence to the criteria for valid requests for assisted dying may be a trigger for civil and/or criminal liability, as well as disciplinary sanctions where the assistor is a medical professional. In this article, we review the criteria and evidence in respect (...) of requests for assisted dying in the Netherlands, Belgium, Oregon, and Switzerland, with the aim of establishing whether individuals who receive assisted dying do so on the basis of valid requests. We conclude that the evidence suggests that individuals who receive assisted dying in the four jurisdictions examined do so on the basis of valid requests and third parties who assist death do not act unlawfully. However, further research on the elements that may undermine the validity of requests for assisted dying is warranted. More research on the reasons why requests for assisted dying are refused is also desirable. (shrink)

As Cohen and Marks (2025) focus their discussion of psychedelic exceptionalism and ethics in the regulatory arena, they rightfully explain that psychedelic exceptionalism also appears in other cont...

Indicators of food sovereignty and food democracy center on people having the right and ability to define their food polices and strategies with respect to food culture, food security, sustainability and use of natural resources. Yet food sovereignty, like democracy, exists on multiple and competing scales, and policymakers and citizens often have different agendas and priorities. In passing a ban on the use of genetically-modified seeds in agriculture, Jackson County, Oregon has obtained some measure of food sovereignty. Between 2016 (...) and 2017 ethnographic research was undertaken in rural Southern Oregon where local community and State of Oregon priorities regarding the use of GMO crops are in conflict. This article presents ethnographic research findings about the expression and negotiation of multiple food sovereignties by civil society in rural southern Oregon and the State of Oregon via democratic processes. In particular, these findings illustrate the effects of socio-political power dynamics on local and state acts of food sovereignty, democracy and agrifood policy by analyzing what the different expressions of food sovereignty reveal for its implementation at the local level. (shrink)

The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A rationing plan such (...) as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed. (shrink)

Background: Debates over legalisation of physician-assisted suicide or euthanasia often warn of a “slippery slope”, predicting abuse of people in vulnerable groups. To assess this concern, the authors examined data from Oregon and the Netherlands, the two principal jurisdictions in which physician-assisted dying is legal and data have been collected over a substantial period.Methods: The data from Oregon comprised all annual and cumulative Department of Human Services reports 1998–2006 and three independent studies; the data from the Netherlands comprised (...) all four government-commissioned nationwide studies of end-of-life decision making and specialised studies. Evidence of any disproportionate impact on 10 groups of potentially vulnerable patients was sought.Results: Rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured , people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS. While extralegal cases were not the focus of this study, none have been uncovered in Oregon; among extralegal cases in the Netherlands, there was no evidence of higher rates in vulnerable groups.Conclusions: Where assisted dying is already legal, there is no current evidence for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician-assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges. (shrink)

Portland, Oregon enjoys a growing reputation as a beacon of urban sustainability. Its modern planning history has seen effectve efforts to curb urban sprawl and introduce a comprehensive mass transit system. More recently, the city has also become a hub for a “makers” movement involving a plethora of local, small-scale craft production. Within this context, Portland is also home to a thriving urban agriculture scene, featuring community gardens, community-assisted agriculture, farmers’ markets, food co-ops, and various farm-based education and outreach (...) programs. While recent case studies of Portland insist that the social sustainability case made for urban agriculture (UA) remains open, this position is arguably unwarranted and lacks an adequate grasp of the critical urban geography perspective developed in the work of David Harvey and Neil Smith. Following the lead of what Chiara Tornaghi calls “the critical geography of urban agriculture,” Portland’s urban agriculture should, on the whole, be seen as an adjunct to rather than a resistance movement against advanced neo­liberal urban governance. (shrink)

Oregon is the only state in the United States where a physician may legally prescribe a lethal dose of barbiturate for a patient intending suicide. The Oregon Death with Dignity Act was passed by voters in 1994 and came into effect after much legal wrangling in October of 1997. At the same time, a cabinetmaker named Pat Matheny was struggling with progressive weakness from amyotrophic lateral sclerosis, or ALS. I met with Pat and his family for a lengthy (...) interview in October 1998 in Coos Bay, Oregon, for a television news report on his decision to get a lethal prescription. Below is an extract from that interview. On the day this introduction was written, 10 March 1999, Pat took the prescribed lethal overdose of barbiturates and died at home. His illness was taking his voice, he could not move his hands or legs, and breathing was becoming very difficult. His mother told me he knew that was for him. (shrink)

There is consensus that children have questionable decisional capacity and, therefore, in general a parent or a guardian must give permission to enroll a child in a research study. Moreover, freedom from duress and coercion, the cardinal rule in research involving adults, is even more important for children. This principle is embodied prominently in the Nuremberg Code (1947) and is embodied in various federal human research protection regulations. In a program named "SATURN" (Student Athletic Testing Using Random Notification), each school (...) in the Oregon public-school system may implement a mandatory drug-testing program for high school student athletes. A prospective study to identify drug use among student-athletes, SATURN is designed both to evaluate the influence of random drug testing and to validate the survey data through identification of individuals who do not report drug use. The enrollment of students in the drug-testing study is a requirement for playing a school sport. In addition to the coercive nature of this study design, there were ethically questionable practices in recruitment, informed consent, and confidentiality. This article concerns the question of whether research can be conducted with high school students in conjunction with a mandatory drug-testing program, while adhering to prevailing ethical standards regarding human-subjects research and specifically the participation of children in research. (shrink)

In 1989 the Oregon Legislature voted not to wait any longer for national leaders to serve up a solution to the problem of the millions of Americans (450,000 in Oregon) who are uninsured for health care. Under the leadership of Senator John Kitzhaber, President of the Oregon Senate, the lawmakers put together a package of bills designed to bring every Oregonian the security of third party financing for needed health care. The Oregon Plan's key innovation is (...) the idea that, from a societal perspective, some health services can be declared more important than others. From that central idea came the thought that the whole range of health services could be arrayed to reflect social priorities relevant to Medicaid budgeting and the design of new health insurance programs for “the uninsured.”. (shrink)

Oregon's Death with Dignity Act was a citizen's initiative passed by the voters in November 1994. After surviving a series of legal challenges, the law allowing physician-assisted suicide became effective on October 27, 1997. Adult residents of Oregon who are terminally ill can make a request to a physician for a lethal medication for the purpose of ending their lives “in a humane and dignified manner.” The physician must determine that the patient has an incurable illness and is (...) competent. The Oregon Department of Human Services collects information regarding compliance with the provisions of the law. This chapter presents demographic data on the 341 patients who have died under the law between 1998 and 2007. Contrary to fears expressed by opponents of the legislation, those who chose assisted death were not the poor or uneducated but the better educated and those with higher incomes. Inadequate pain control was cited only by about one third of those who made use of the law. Instead of concern about good end-of-life care, the fear of losing control and dignity was one of the primary reasons for choosing assisted death. As a result of rapid expansion of palliative care, by 2007 a full 88% of those who chose assisted death were being cared for by a hospice. Despite some remaining problems such as the difficulty of recognizing psychiatric disorders, experience with the law has on the whole been positive and safeguards against abuse appear to be working. (shrink)

Battin et al examined data on deaths from physician-assisted suicide (PAS) in Oregon and on PAS and voluntary euthanasia (VE) in The Netherlands. This paper reviews the methodology used in their examination and questions the conclusions drawn from it—namely, that there is for the most part ‘no evidence of heightened risk’ to vulnerable people from the legalisation of PAS or VE. This critique focuses on the evidence about PAS in Oregon. It suggests that vulnerability to PAS cannot be (...) categorised simply by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. It also argues, on the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, that, contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et al reported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS. (shrink)

Recognition of the need to ration care has focused attention on the concept of "basic care." It is often thought that care that is "basic" is also morally prior. This article questions that premise in light of the usual definitions of "basic." Specifically, it argues that Oregon's rationing scheme, which defines "basic" in terms of cost-effective care, fails to pay sufficient attention to important ethical principles such as justice.

This article examines the efforts by the Northwest Treeplanters and Farmworkers United union to organize Mexican migrant farmworkers in the Willamette Valley. It focuses on the union's 1995 organizing campaign of strawberry pickerśs, the largest campaign in the history of Pacific Northwest agriculture. To provide context for the union's efforts, the article develops the historical role and changing nature of Oregon agriculture, sketches the politics of agriculture in the state, and describes the industry's labor system. The article concludes that (...) significant gains for strawberry pickers were made during the 1995 campaign; the long-term consolidation of those gains remains to be demonstrated. (shrink)

In _Liberalism’s Troubled Search for Equality_, Robert P. Jones presents a penetrating examination of physician-assisted suicide that exposes unresolved tensions deep within liberal political theory. Jones asks why egalitarian liberal philosophers—most notably, Ronald Dworkin and John Rawls—support legalized physician-assisted suicide in direct opposition to groups of disadvantaged citizens they theoretically champion. Jones argues that egalitarian liberals ought to oppose physician-assisted suicide—at least until we find the political will to ensure access to health care for all. More broadly, Jones challenges progressives (...) to find the heart of the liberal tradition not in allegedly neutral appeals to “choice” but in a renewed commitment to equality and social justice that welcomes public religious voices as allies. “_Liberalism’s Troubled Search for Equality_ is the most sophisticated analysis I have read that gives a social and philosophical context to the Oregon debate on assisted death. Jones’s meaningful discussion of moral values in liberal political philosophy incorporates strong scholarship and an impressive use of interviews and ethnography.” —Courtney S. Campbell, Oregon State University "A fresh, challenging, and timely approach to the political intersections of religion and progressive politics. Cutting through the headlines on the contentious physician assisted suicide issue, Jones's intellectually rigorous focus on equality and justice as the key to shaping an authentic liberal response will have great appeal across political and religious lines. His approach offers precisely the right prescription for a stronger progressive movement." — Rabbi David Saperstein, Religious Action Center of Reform Judaism. (shrink)

This article is an attempt to evaluate the Oregon plan from the perspective of a Scandinavian national health care system. The Nordic welfare states are marked by a strong emphasis on equality. As an example of an egalitarian system we present the Norwegian health care model in part one. In part two, the arguments in favor of a one tier system in Norway are presented and compared to Oregon's two tier system. Although we argue, in part three, that (...) a comparison of the degree of explicitness in the prioritization process shows that Norway has much to learn from Oregon, we do believe that the Norwegian system has some attractive elements that may function as an important corrective. In part four we present the Norwegian Guidelines for priority-setting and discuss the weight assigned to the severity of disease criterion. It is argued that the exclusion of information about the severity of disease partly explains the counterintuitive ranking of treatment-condition pairs in Oregon's initial method based on the principle of health maximization. A normative analysis of the conflicting norms of efficiency and equality of results is called for. The final part of the paper is devoted to the problem of rigidity. Henry J. Aaron has argued that the Oregon system is insensitive to inter-individual variations within each diagnosis-treatment pair. This objection is a severe one, since the system might end up treating patients unfairly on the individual level. To overcome this problem, we suggest a selection rule that should be more capable of dealing with the problem of rigidity. (shrink)