Ballot Measure 16, titled "The Oregon Death with Dignity Act," was narrowly approved in the general election, with 51% of voters in favor and 49% opposed. The initiative was sponsored by a group called Oregon Right to Die and was strongly supported by the Hemlock Society and patients' rights advocates. During the campaign, the Roman Catholic Church and most Protestant denominations opposed the measure, as did the American Medical Association [1]. Weeks before the election, the Oregon Hospice Association and the Oregon State Pharmacists Association declared their formal opposition. The Oregon Medical Association debated the issue and decided to take a neutral stand on the measure; this reflected the division of opinion among its members. Thus, organized opposition by the health professions played a less prominent role against the Oregon assisted suicide initiative than it did against the unsuccessful initiatives to legalize both assisted suicide and euthanasia in Washington (1991) and California (1993).

Shortly after the election, a lawsuit was filed in federal court, challenging the law on constitutional grounds [2]. In August 1995, an Oregon judge ruled that the measure was unconstitutional because it did not give equal protection against suicide to terminally ill persons. The ruling is currently under appeal. Legal experts in Oregon and elsewhere predict that the legal status of Ballot Measure 16 will remain suspended for at least 1 year, possibly until the U.S. Supreme Court decides the fate of assisted suicide in the United States.

If enacted, the Oregon law will allow a primary care physician to prescribe a lethal dose of medication at the request of a terminally ill patient who intends to use the medication to commit suicide [3]. Only competent adults who are Oregon residents and who are expected to live less than 6 months would be eligible. A second physician must confirm the diagnosis and ensure that the patient is capable and acting voluntarily. The patient must make two oral requests, separated by a 15-day waiting period, and one written request. The physician has the right to decline to participate. The physician must refer the patient to a mental health professional if the patient's judgment appears to be affected by depression or another mental disorder. The physician must ask the patient to disclose his or her intentions to family members, but the patient can refuse to do so. Insurance companies may not withhold death benefits from patients who act in accordance with the law. Physicians are required to report participation to the state health division, but those who act in good faith with the law are protected from both professional discipline and legal liability.

Voters' approval of Ballot Measure 16 has been widely interpreted in Oregon as a reflection of a broad rejection of medicine's approach to the care of dying patients more than as a specific endorsement of assisted suicide. During the campaign, proponents of the measure emphasized the imagery of dying patients with unrelieved suffering and a medical system that could not compassionately care for them. As a result, the election spurred a new willingness among professional organizations and health care systems to improve care of the dying. In the process of planning for possible implementation of the law, each health care system in Oregon has been identifying and addressing obstacles to comfort care. Physicians, nurses, and other health professionals who oppose assisted suicide have taken an active role in adding to this pressure for change.

Many obstacles to comprehensive end-of-life care for terminally ill patients are falling away as a result. For example, some hospice programs report a 20% increase in referrals since the vote; several factors may account for this. First, the campaign enhanced awareness of hospice care among patients, families, and health care providers. Second, reimbursement for hospice services has improved. Eligibility for the Oregon Health Plan, which covers hospice benefits, was extended to elderly and disabled Oregonians on 1 January 1995 [4]. In addition, one large prepaid health plan has deleted its cap on hospice care and now provides full benefits. Finally, physician reimbursement has increased. In January, Medicare began reimbursing physicians for phone calls and other oversight activities of hospice patient care.

Several Oregon hospitals have developed or expanded the scope of comfort care consultation teams since November. These interdisciplinary teams, using a hospice model, act as consultants to enhance comfort care not only for terminally ill patients but for other patients who have life-threatening illnesses in various inpatient and outpatient settings. These teams offer expertise in managing an array of physical and psychological symptoms and the social difficulties common to dying patients. The speed with which these teams have been developed shows the extent of staff and administrative support for this resource in the wake of the election.

Those of Oregon's health care systems that are sponsored by Catholic religious communities have announced that they choose to exercise their right not to allow physician-assisted suicide within their facilities and services, even if the ballot measure is ultimately enacted. They have responded to passage of the measure by collaborating to develop a plan for improving end-of-life care and clinical decision-making across the spectrum of care settings. They have proposed a new practice model that emphasizes compassionate and skilled comprehensive end-of-life care in the acute setting and in all other sites of care. Their proposed strategies include patient and staff education, interdisciplinary consultation for symptom management, professional performance standards, total quality improvement, and continuous quality management efforts. This state-wide collaboration is now being extended to involve Catholic health care organizations nationally.

The need to improve the education of medical students, residents, practicing physicians, and other health professionals in comfort care and other issues surrounding dying is also being recognized. An expanded curriculum in comprehensive end-of-life care for medical students at Oregon Health Sciences University was developed after the November election and implemented in May 1995. Recognizing that many physicians fear moral, professional, or legal consequences if they prescribe narcotic analgesics in doses that might hasten death [5, 6], the Center for Ethics in Health Care at Oregon Health Sciences University, the Oregon Board of Medical Examiners, the Oregon Medical Association, and the local Foundation for Medical Excellence have collaborated to develop a series of courses throughout the state to address this fear.

Some commentators have argued that legalizing physician-assisted suicide would undermine the provision of comprehensive end-of-life care by providing an easier alternative [7, 8]. The initial response to voter approval of assisted suicide in Oregon suggests the opposite [9]. The public has been telling the health care community for a long time that, when it comes to care of the dying, we are not meeting their needs and those of their loved ones [10]. It took a wake-up call like this, however, to motivate the health care system to make necessary changes. Concerted effort by the health care community is needed to ensure that these trends continue, regardless of the ultimate legal status of assisted suicide.