The Death Debate
Early this year, Booth Gardner surprised people.
During an awards dinner for TVW, the cable channel that covers state government, the popular former two-term governor used his time at the podium to serve up a show stopper: death. He announced he had one more political fight in him—for the right of terminally ill people to end their lives with prescribed medica- tions. At 70 years old and suffering from advanced Parkinson’s disease, Gardner’s decision to spearhead a death with dignity ini- tiative is not an abstract exercise.
He told the crowd that he faced many tough choices through- out his life, and wanted to be allowed to do the same at the end. As for fighting for an initiative at the same time he battles Parkinson’s, he said, “I don’t know if I’ll make it, but I’m going to make the effort.”
There’s only one problem. There is no Washington death with dignity initiative. That’s what the people who would be planning for an initiative—if there were an initiative—keep telling me. No political action committee. No war chest. No nothing.
What there is is momentum. Even before Gardner primed the pump in February, things were starting to move. In January, the U.S. Supreme Court rejected efforts by former Attorney General John Ashcroft to use federal drug laws to override Oregon’s death with dignity law, the country’s only law legalizing physician-assist- ed suicide. The ruling indirectly reasserted states’ rights to legislate their own medical affairs.
Nine days later, Washington state Senator Pat Thibaudeau of Seattle (D-34th legislative district) introduced the Washington Death with Dignity (DWD) Act (mirroring Oregon’s) in Olympia. It stalled in committee, but no one expected more than that. Meanwhile, polls consistently show a majority of Americans support physician-assisted suicide for the terminally ill.
For the first time since 1991, when Washington voters defeated a death with dignity initiative, local right-to-die activists are seri- ously considering (unofficially, of course) going to the people again. But it won’t be easy. If an initiative comes to the state in 2008 (as Gardner suggested), it will bring a protracted, expensive and emotional battle in the middle of what promise to be con- tentious presidential and gubernatorial races. The stakes are high on both sides. Proponents know that if an initiative suffers a sec- ond defeat here, it’s hard to imagine the issue could rise from the ashes any time soon. If an initiative passes, an invisible wall will be breached, dealing a significant blow to an opposition that prides itself on containing assisted suicide in Oregon.
In August of 1999, Roger Dean Watanabe, a professional counselor from Ontario, Oregon was told he had Stage 3 colon cancer. In his early 50s and still reeling from the death of his mother from cancer a few months earlier, he hunkered in for the fight. After three surgeries and two rounds of chemotherapy, he was given a terminal prognosis. He decided he wanted the option of choosing when he would go.
“It is the freedom of choice I felt so strongly about, freedom of being able to know your own destiny when you are dying and being able to choose when and where it’s going to happen,” Watanabe said in a video recording made by a buddy. For propo- nents of physician-assisted suicide, choice in one’s fate is a crucial argument for death with dignity statutes.
Watanabe planned to take advantage of Oregon’s Death with Dignity law if things got too bad, when in November 2001, U.S. Attorney General John Ashcroft issued a directive banning Oregon doctors from prescribing drugs for suicide under the Controlled Substances Act. This was immediately challenged by the state, and Watanabe became the third patient-plaintiff. He would not live to read the Supreme Court’s rebuff of Ashcroft, issued earlier this year.
In March of 2002, he swallowed a liquid barbiturate in the com- pany of friends, becoming one of the more than 246 people to end their lives under Oregon’s Death with Dignity law.
For proponents of physician-assisted suicide, Watanabe’s story is a moving example of how the law works and why it is neces- sary. But Wesley J. Smith might call it an example of “Euthanasialand.” A senior fellow at the Seattle-based Discovery Institute and an outspoken opponent of assisted suicide, Smith says ideal scenarios involving competent, insured, uncoerced peo- ple like Watanabe only pertain sometimes, and that it’s for other real-world cases that assisted suicide must be stopped.
“When you look at the headlines about elder abuse. When you look at the headlines about HMOs cutting levels of care, when you look at the headlines about people without medical insur- ance, you begin to think that this is the context within which assisted suicide will be practiced,” Smith says. “Then people begin to think twice about it.”
Smith and other opponents avoid the sanctity of life arguments that typify the abortion debate, and focus on distinctly secular concerns. They say patients will be pressured into committing suicide by family members who see them as a burden or by a medical-industrial complex that sees them as too expensive. They argue that the reasons people seek suicide—such as pain and depression—are treatable, and that assisted suicide, even as it is narrowly defined in the Oregon statute (see “The Oregon Trail,” below) devalues life and serves as a stepping stone toward a more broadly applied euthanasia.
“Legalizing assisted suicide...sends insidious messages that some lives are not worth living and protecting from destruction,” says Smith, who outlines some of these positions in his book, Culture of Death: The Assault on Medical Ethics in America. “If we say that somebody can die because they are terminally ill, well, why shouldn’t somebody who is disabled and going to live for 20 years in more suffering than a dying person have assisted suicide? That’s the next step.”
So far the arguments against assisted suicide have prevailed nearly every- where, beginning in Washington. In 1991, the Evergreen State was the first to put physician-assisted suicide to a vote of the people. Initiative 119 would have legalized “a medical service, provided in person by a physician, that will end the life of a conscious and mentally competent qualified patient in a dignified, painless and humane manner, when requested voluntarily by the patient through a written directive.” The ini- tiative did not have many of the restrictions and safeguards contained in the Oregon law.
Despite an early double-digit lead in the polls, the initiative ran into trouble.
In October 1991, Dr. Jack Kevorkian, the Michigan pathologist who had stirred debate early in the year by helping a woman with Alzheimer’s to kill herself, attended the deaths of two more women at a Michigan cabin. Marjorie Wantz, a 58-year old suffering from chronic pelvic pain, killed herself with a sui- cide machine designed by Kevorkian that allowed her to self-inject lethal drugs. Sherry Miller, a 43-year old with multiple sclerosis, died from carbon monoxide inhaled through a face mask.
“It made a big splash,” remembers Tom Preston, M.D. A cardiologist, Preston was one of the first, if not the first, Washington doctor to publicly advocate death with dignity. (In 1991, the Washington State Medical Association opposed I-119.) “Our opponents were able to say, ‘see, that’s what they’ll do. They’ll just take anybody who wants it and kill, kill, kill.’”
The second major factor was a well-financed No! campaign. Money poured into the state, much of it through Catholic organizations. “At the very end of the campaign, the opposition outspent the Citizens for Death with Dignity 100 to one,” says Robb Miller, executive director of Compassion & Choices of Washington, an end-of-life advocacy and counseling organization that supports “patient-directed dying.” The money went into advertising that fueled fears that the sick, poor and vulnerable would be pressured into killing themselves. “Let me tell you, that’s powerful stuff,” Preston says. “We really could not counter that.”
Dan Kennedy, CEO of Human Life of Washington, a pro-life organization in Redmond, was an active participant in the I-119 Vote No! campaign. He says the fear mongering came from the other side. “It’s a very emotional issue,” Kennedy says. “Those that want to promote assisted suicide use that in a very devious man- ner. No one wants to imagine their last days in agony and suffer- ing, and neither do we. That’s why we put out there that it’s not really an issue. The last few months of life can be one of the most poignant and meaningful of our entire lives.”
The initiative failed 54 to 46 percent. Since then four other states have taken the issue to the voters: California in 1992, Oregon in 1994, Michigan in 1998 and Maine in 2000. In each case, except Oregon, the story has been the same. Polls favor pas- sage early in the process, but initiatives fail at the ballot.
“That’s a common pattern for all initiatives,” says Mark Smith, a political scientist at the University of Washington. There’s a lower threshold for people working to defeat an initiative. The consequences of another failure could be dire. “Running an initiative and having it fail—that could kill the idea in the future,” Smith says.
“Those of us who were here in 1991 know it’s a lot of work,” adds Preston, who self-published Patient-Directed Dying: A Call for Legalized Aid in Dying for the Terminally Ill this year to get his mes- sage out. “We figure it will cost millions....So one does not go into this cavalierly. We have to think it through very clearly.”
Not everyone is focused on the initiative track record. Some right-to-die activists say 1991 and 2008 are different situa- tions, for one very important reason: Oregon. “We can look across the border and see that the sky has not fallen,” says Kathryn L. Tucker, legal director for Compassion & Choices. Tucker has been at the heart of several key legal battles including Oregon v. Ashcroft.
Physician-assisted suicide in the United States is no longer a hidden reality or a hypothetical. It’s a legal, medical practice with 246 case histories.
“Oregon’s law has stood the test of time,” says Peg Sandeen, executive director of Death with Dignity, the Portland-based group that wrote Oregon’s law. “When all those folks in opposition say, ‘oh, people with disabilities are being killed; family members want to get rid of grandma so they can get her money,’ we can say, ‘it doesn’t happen.’”
Predictions that people without educa- tion, without insurance and without the benefit of hospice would be pressured into suicide are not reflected in the num- bers. Of those to take a lethal dose during the past eight years, 62 percent had attended or graduated from college and only 9 percent had not graduated from high school. More than 62 percent had private insurance and 37 percent Medicare or Medicaid. Eighty-seven percent were enrolled in hospice.
In addition to data compiled by that state, researchers at Oregon Health and Science University (OHSU) in Portland have run several surveys of doctors, nurses and hospice caregivers, including DWD supporters and detractors.
“Patients make the choice to request assisted suicide because they want to con- trol the timing and manner of their death,” says Dr. Linda Ganzini, lead OHSU researcher, about the results of a 2002 sur- vey. In this one study, hospice caregivers said patients ranked depression, lack of social support and fear of being a financial drain on family members as among the least important factors in their decision.
And a positive outcome is that it has raised awareness of end-of-life issues, says Anne Koepsell, executive director of the Washington State Hospice and Palliative Care Organization (WSHPCO), which opposed Washington’s 1991 initiative. “There seems to be evidence that the physi- cians and other health care providers are discussing hospice and end-of-life options, in addition to just physician-assisted suicide with their patients, which is probably one of the major benefits.”
Opponents aren’t buying this sunny version. “Oregon is their beachhead,” says Wesley Smith about those who support assisted suicide. “They are desperately trying to spread the policy from Oregon.”
One outspoken critic is Dr. N. Gregory Hamilton, a Portland psychiatrist and co-founder of Physicians for Compassionate Care (PFCC), an organization with ties to the Catholic Church, which opposes DWD laws. In a hotly debated case study published in the American Journal of Psychiatry last year, Hamilton claimed that he and his wife had repeated contact with one Oregonian who received a lethal prescription despite the fact the man was severely depressive and delusional, which should have disqualified him. He died of natural causes two years later.
Aspects of the account have been challenged, but much of the story relies on the Hamiltons’ first-hand experience, which they stand by. Dr. Hamilton claims that this example demonstrates how the statute is inadequate for tackling issues of competency at the end of life. He also complains that even after the patient was hospitalized, he was able to keep the drugs. Under the Oregon statute, there is no follow-up required on the part of prescribing physicians after the prescription is written.
During a U.S. Senate Judiciary Committee hearing in May, Rita Marker testified that “the number of reported assisted-suicide deaths may be inaccurate or incomplete.” Marker is the executive director of the International Task Force on Euthanasia and Assisted Suicide, an Ohio-based organization fighting against an expansion of laws like Oregon’s. “The DHS [Oregon Department of Human Services] has to rely on the word of doctors who prescribe the lethal drugs,” she complained. She added a laundry list of claims to Hamilton’s including problems with accurately determining life expectancy, lack of resources to investigate complications and disregarded safeguards.
While the nuts and bolts of what has really happened in Oregon interests U.S. senators, these details probably won’t persuade Washington voters in the heat of an initiative campaign if it comes to that. “I don’t think you’ll resolve this with facts. This is very much a values issue,” says UW’s Mark Smith.
The values side of the fight against assisted suicide, usually the purview of the church, has a strong new ally—people with disabilities who say assisted suicide targets them.
“I never understood why it is that when a teenager wants to commit suicide, we call out everybody and their brother to prevent it because it would be a tragedy, but if somebody with a disability would want to do it, it seems objectively sensible,” says Joelle Brouner, an Olympia resident with cerebral palsy.
Brouner is a member of Not Dead Yet (NDY), a national disabilities rights organization founded in Lake Forest Park, Illinois, specifically to fight this fight. In 1996, NDY attracted attention with protests at the home of Jack Kevorkian after he helped a woman with non-terminal degenerative spinal disease to commit suicide. Kevorkian is a lightning rod for many in the disabilities community because the majority of the people he helped to die were disabled, not terminally ill.
A self-described Paul Wellstone Democrat, Brouner would oppose a right-to-die initiative. “A lot of people are like me,” she says. “They consider themselves progressive but they don’t see sup- port on the left for a more nuanced consideration of the consequences of physician-assisted suicide.” Brouner is well aware of the main reasons patients in Oregon give for seeking physician-assisted suicides: loss of independence, loss of quality of life and loss of dignity—realities she and others like her deal with every day.
“I think it’s a news flash to people that people with disabilities want to live,” Brouner says.
But Brouner and Not Dead Yet don’t speak for everyone in the disabilities community. There has been a loud and thought- provoking airing of differences. “They [Not Dead Yet] operate from a position of vulnerability, which I reject,” says Paul Spiers, executive director of Autonomy Inc., a national disabilities group founded in 1997 to counter the claims of Not Dead Yet.
Spiers told the senate hearing in May: “Indeed, many people prob- ably will choose to end their lives because of the very limitations or handicaps that many Americans with disabilities live with every day. Therefore, it has been argued that this will devalue the lives and exis- tence of persons with disabilities, who will then be encouraged to end their lives. This is referred to as the ‘slippery slope’...But the truth is, in nearly a decade of the Oregon law, the slippery slope has not mate- rialized. The feared abuses against people with disabilities have not occurred and are, in fact, best prevented by precisely the safeguards included in the Oregon law.”
Despite the internal debates, the high profile of Not Dead Yet could recast the debate this time around.
Meanwhile, as activists in both camps debate strategy and politics, all across the state, terminally ill people struggle to face the end-of-life battles within the letter of the law. In March 2004, Heather Diana Woods, a naturopathic doctor living in Port Townsend, discovered a mass in her breast. “When she told me she had a lump, she said, ‘I know this is different,’” her husband David Ritt remembers. She was right. Woods had a par- ticularly aggressive form of cancer, a “nine” on a scale of 1 to 9.
A vibrant, sensible woman, she marshaled everything allopathic and naturopathic medicine had to offer including surgery, chemotherapy, radiation, brachytherapy, hyperthermia and intensive vitamin C ther- apy. In January 2006, doctors declared her cancer in remission. When it returned with a vengeance only four weeks later, Woods’ only option was an extremely toxic chemo nicknamed the Red Death.
“I was thinking, this is the next thing you’ll do,” Ritt says. “We’ll buy time until they find a cure.” Ritt, who is a trombonist with the Seattle Symphony, met his wife in 1989. They married in 1991.
But Woods saw things differently and decided against further treat- ment. At one point in the middle of things, “She said, this would all be worth it if she survived. But that the pain was so bad, she wished she had never been born,” Ritt says.
Struggling to breathe even with the help of two oxygen breathing machines, Woods wanted to end her life. Hospice nurses told her she could refuse food and water and be sedated, essentially slipping into a coma until she succumbed. That option frightened her, Ritt says, because she was afraid of suffocating to death.
Ritt contacted Compassion & Choices of Washington. In addition to advocacy, the group provides counseling at the end of life for ter- minally ill people, including advice and support for patient-directed dying. They do not provide or administer medication, which would be against the law.
The patient has to get his or her own medicine. “We had to go through a series of machinations that were barbaric,” Ritt says. “It was covert and burdened.” But he adds: “I was willing to go to jail to facilitate her death.”
One evening in April, after saying goodbye to friends and family in the course of a few days, Woods took a lethal dose of drugs, which had been prescribed for other legal uses. Friends repeated a Tibetan chant to bring her a good incarnation as she fell asleep. After about an hour, her breath- ing became irregular. The sound distressed Ritt. “I told her whenever you are ready to go, you can go. And she did.” She was 55 years old.
THE OREGON TRAIL
Deconstructing the Death With Dignity law in Oregon, the only state where it’s legal
If Oregon’s experience demonstrates anything, it’s that passing a law is just the first hurdle. Twice, Oregonians affirmed their support for the Oregon Death with Dignity (DWD) law, first by passing a citizen’s initiative by 51 percent in 1994. Almost immediately, it was challenged. A legal injunction delayed imple- mentation, but after proceedings that included a petition denied by the U.S. Supreme Court (the first of two challenges to make it to the highest court), the injunction was lifted on October 27, 1997. Soon after, a measure asking Oregon voters to repeal the act was placed on the general election ballot. Voters rejected this measure by 60 percent, making Oregon the first state with legal physician-assisted suicide. Nine years later, it remains the only one.
Under the law, Oregon residents who are at least 18 years old, capable of making and communicating health care decisions, and diagnosed with a ter- minal illness that will lead to death within six months, are eligible to request a prescription for lethal medication from a licensed Oregon physician. There are additional safeguards, including but not limited to the requirement that patients must make two oral requests with at least 15 days in between, and two physicians must confirm the diagnosis and prognosis to determine whether the patient is capable of making the decision. Most proposed DWD laws mirror Oregon’s.
According to the Oregon Department of Human Services, from 1998 to 2005, 390 terminally ill people received DWD prescriptions in Oregon, and 246 indi- viduals took their lives. This represents a tiny percentage of the 74,967 Oregonians who were dying from the same underlying diseases as those who took their lives, during that same time period. The overwhelming majority of those to commit suicide suffered from malignant neoplasms (cancer), followed by amyotrophic lateral sclerosis (also known as ALS and Lou Gehrig’s Disease), chronic lower respiratory disease (including emphysema) and HIV/AIDS.
MUSTERING HIS ENERGY FOR ONE MORE FIGHT, FORMER GOVERNOR BOOTH GARDNER IS A FORMIDABLE CHAMPION FOR DEATH WITH DIGNITY
At this summer’s Strawberry Festival on Vashon Island, former two-term Washington Governor Booth Gardner soaked up the sun along with throngs of former constituents. Always popular on his adopted home island, Gardner found himself even more the center of attention than normal. That’s because he put himself back in the public eye early this year by announcing his plan to spearhead passage of an assisted-suicide law in the Evergreen State.
“People I didn’t know were coming up to me and acting like they knew me and saying this is a great initiative. I got that all night long,” Gardner said the next day. Gardner’s announcement was inspired by personal experience. For the last 14 years, he has struggled with Parkinson’s disease, a progressive brain disorder with no cure. The condition causes loss of balance, rigidity, tremors and depression. In February, he told The Seattle Times that assisted suicide is about choice and control. “Since I’ve had Parkinson’s, obviously I’ve thought about the end,” Gardner says. “I’ve got limited time left. I want to keep busy, and when the day comes when I can no longer keep busy, and I’m a burden to my wife and kids, I want to be able to control my exit.”
Many of the people who have approached Gardner since his announcement talk about their first-hand experiences. “I’ve heard more stories than I care to hear,” the 70-year-old Tacoma native says. While most of the feedback has been supportive of a law legalizing physician-assist- ed suicide in limited cases, he says he also hears from Washingtonians who disapprove, most frequently on religious grounds, including his own son. “My son is a born again-Christian,” Gardner says about Doug Gardner. “He’s a good guy and he has a great family
and we disagree on this.” Gardner knows that the majority of the fight over this
issue will come from organized religion, which has been a formidable force in the past and will require all the fight he can muster.
Since his announcement, Gardner has had two Deep Brain Stimulation (DBS) surgeries, which involve implant- ing electrical stimulators in the brain to reduce the tremors, slowness, stiffness and involuntary movements associated with advanced Parkinson’s. During his reha- bilitation and recovery, he continued, as much as possi- ble, to work for his cause.
When we caught up with him the day after the Strawberry Festival and the day before his sec- ond brain surgery, pretty much everything about the future of a death with dignity law—other than Gardner’s full-throated support—was up in the air, including how to pass the law.
Gardner favors an initiative but is open to working with the legislature. He also said that initia- tive supporters are split between pushing for a 2007 or 2008 campaign.
How the law will read is equally uncertain. Most seasoned activists say duplicating Oregon’s law is the most pragmatic approach. But Gardner isn’t sure. Early in the year, he said he sup- ported a controversial provision that would allow doctors to give lethal injections, something some activists including Robb Miller, executive director of Compassion & Choices of Washington, see as politically untenable. Six months later, Gardner is not making statements for the record. There is a chance that he could push for a revision of Oregon’s requirement that patients who receive assistance have a six-month terminal diagnosis. Because Parkinson’s is not a fatal dis- ease, Gardner might not qualify for a lethal prescription under a law like Oregon’s. In that state, no one with a primary diagnosis of Parkinson’s has used the law since it passed.
What proponents can agree on (and opponents say the same) is that having a popular and well- known champion like Gardner in the mix changes the calculus for death with dignity in Washington. Gardner appears to recognize his influence and power more than anyone. When asked when we’ll see the next big political push for this issue, he says, “When Booth gets well,” referring to the recovery time for his brain surgery. That puts him back on the campaign trail this fall.
SPEAKING OF DEATH
The terminology of death with dignity
A few seconds into any conversation on death with dignity (DWD) initiatives, and you can pretty well tell where people stand along the spectrum. The political gulf between “patient- directed dying” and “doctors killing” is hard to miss.
So in an effort to avoid some of the linguistic landmines posed by this topic, we take a moment to lay out the context for the terminology in this story.
The goal is to use the most descriptive and objective language available to define the central act of a terminally ill
person taking physician-pre- scribed medication to end his or her life. For the act itself in this story, we opted for the frequently used physician-assisted suicide. The downside of this word choice is that while suicide is legal, it has strong negative connotations that can blur the debate. Most religions have serious prohibitions against it and, as a society, we have laws that permit us to intervene against a person’s wishes to prevent suicide.
Groups like Compassion & Choices (C&C) use choice-in- dying or patient-directed dying. They say “dying” conveys better than “suicide” the idea that terminally ill people are already dying, and choose not so much to end life but to hasten death. In June, the phrase “aid in dying,” to describe this medical practice, was added to California’s pending assisted- suicide law. (The bill was defeated; see sidebar on page 127.) While “patient-directed dying” reflects the patient-con- trol intent of the law, it leaves a key component out of the equa- tion. After all: No doctor, no need for a new law.
Opponents to DWD laws often refer to “physician-assisted suicide,” but they describe it as legalized killing and euthanasia.
Strictly speaking, “killing” is inaccurate. The doctors only prescribe medication, and are often not present at the death.
Euthanasia is also widely used by opponents, particularly the International Task Force on Euthanasia and Assisted Suicide, an Ohio-based organi- zation working against legaliz- ing assisted suicide. Euthanasia simply means “a gentle and easy death.” But over time and in this context, it has come to mean death administered or imposed from the outside. In addition, the term also has powerful connotations, conjur- ing, among other things, the systematic killing by the Nazis of people deemed unworthy during World War II.
DWD AROUND THE COUNTRY
WHAT’S HAPPENING IN OTHER STATES
Oregon was the first state to pass an assisted-suicide law with the Oregon Death with Dignity Act in 1994. In addition, at least five states have put assisted suicide to the vote.
California: In 1992, one year after a citizens’ initiative to legalize physician-assisted suicide failed in Washington, a similar measure, Proposition 161, was defeated by 54 percent of California voters. This year, the California Compassionate Choices Act passed through the state Assembly before it was rejected by a Senate committee in June.
Hawaii: In 2002, the Hawaii state Senate defeated a House-passed bill to allow doctor-assisted suicide. Since then, similar bills have stalled in the legislature.
Maine: Maine voters rejected a proposal by 51 percent in November 2000 to legalize physician-assisted suicide. A similar bill failed in the Maine House in 1998.
Michigan: In response to Dr. Jack Kevorkian’s assisting more than 100 suicides, legislators in his home state passed a law specifically banning physician-assisted suicide in 1998. An effort to overturn the new law by ballot initiative failed in the fall. Voters rejected that initiative by more than 2-to-1.
Washington: The country’s first DWD initiative was defeated here in 1991. Earlier this year, Senator Pat Thibaudeau introduced a death with dignity bill (modeled on Oregon’s) in the Senate. The proposal did not make it out of committee. With the departure of Thibaudeau from the senate this year, state Senator Darlene Fairley, a Democrat representing Kenmore/Shoreline/Lake Forest Park, says she plans to sponsor the legislation again in the next session. Early this year, former governor Booth Gardner announced plans to spearhead a death with dignity initiative.
Assisted-suicide bills have been introduced but made little progress in other state legislatures, including New Hampshire, Connecticut, Vermont and Arizona.
Across the pond: In 2001, the Netherlands was the first country to legalize assisted suicide, codifying a stand- ing non-prosecution agreement between the Netherlands Ministry of Justice and the Royal Dutch Medical Association. Belgium legalized it in 2002. In May 2006, the British House of Lords rejected a right-to-die bill based on the Oregon model.