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President's Column

Attacking physician-assisted suicide at the expense of patient care

From the September 1998 ACP-ASIM Observer, copyright © 1998 by the American College of Physicians-American Society of Internal Medicine.

By Harold C. Sox, FACP

My topic this month concerns very troubling legislation now before Congress. The subtext involves the interplay of ideology and public policy.

In June, I received a telephone call from a reporter who wanted to know the College's position on a new bill in Congress. After the citizens of Oregon voted to legalize physician-assisted suicide, Congress began an inquiry into whether the Drug Enforcement Agency (DEA) had jurisdiction over the use of narcotics for physician-assisted suicide in that state. When the Attorney General ruled that the DEA did not have jurisdiction, Congressional opponents of physician-assisted suicide proposed legislation that would give the DEA that authority.

The House version of the bill (H.R. 4006) would "clarify Federal law to prohibit the dispensing of a controlled substance for the purpose of causing, or assisting in causing, the suicide or euthanasia of any individual." In other words, it would modify the Controlled Substances Act to revoke the DEA registration of physicians who had used narcotics to help a person end his or her life.

I told the reporter that ACP-ASIM did not have a policy on the proposal. The following day, however, the College's Health and Public Policy Committee approved a statement opposing the bill, and the Board of Regents followed suit on July 11. Then, on July 31, I appeared on behalf of ACP-ASIM before a hearing of the Senate Judiciary Committee to testify about the Senate's version of the bill (S. 2151).

Sen. Orrin Hatch (R-Utah), who chaired the hearing, was the only senator present for most of the hearing. The first witnesses were the bill's sponsor and Oregon's two senators, who said that while they do not support physician-assisted suicide, they oppose the bill as an infringement upon their state's right to regulate medical practice. Officials from the DEA and the Department of Justice in turn testified as to why the Department of Justice ruled that the DEA does not have jurisdiction in this matter. Finally, six witnesses represented various groups whose interests were at stake. It was during this time that I presented the College's testimony, which focused on two issues. (For the full text of ACP-ASIM's oral and written testimony, go to ACP-ASIM Online at www.acponline.org/home/policy.htm)

Our position

First, the College argued that the proposed legislation would increase suffering in dying patients. The best way to eliminate physician-assisted suicide is by providing excellent end-of-life care, which ideally prevents the circumstances that lead dying patients to consider taking their lives. Severe pain is the most feared symptom in dying patients, and physicians are learning to be more aggressive with narcotics to control that pain.

We argued that the threat of being denied DEA registration might lead many physicians to avoid prescribing large doses of narcotics to relieve pain in dying patients, lest they invite the scrutiny of the DEA. We cited a survey of 1,200 New York state physicians, most of whom said that they had on occasion prescribed less effective pain medication in order to avoid the requirement that they notify the state that they had prescribed a narcotic. This legislation places at risk our recent progress in managing pain in dying patients.

Second, we tried to show how the Senate bill could harm both physicians and the families of deceased patients. If the legislation is implemented, the DEA can take one of two approaches in seeking out instances of physician-assisted suicide: It can either wait for people to accuse a physician or it can look for cases of physician-assisted suicide.

We tried to show that the second approach would lead to many false-positive identifications, and that the process of building a case against a physician would cause great harm not only to the practitioner but also to the deceased's family members. How would the DEA know which of the 6,000 deaths that occur every day was due to physician-assisted suicide? The DEA could identify people who had died after receiving a prescription for narcotics, but proving that a dying patient had committed suicide would require testimony from the patient's family. Either the DEA would call upon the family, or the physician would seek the family's help in his or her defense.

The rarity of physician-assisted suicide would also require the DEA to investigate many deaths to identify a single violation of the law. In Oregon, for instance, where physicians are required to report their role in physician suicide, only five citizens have committed suicide with a physician's assistance during a period in which 10,000 died at home of natural causes. All in all, many physicians could undergo investigations, creating a chilling effect for other physicians. Each investigation would be a warning to other physicians, who might alter their prescribing practices to avoid trouble.

Get involved

Currently, both the Senate and House version of this legislation have considerable momentum. There is a great deal of pressure to present them for a floor vote before the fall elections, and Senate staff expect that the Judiciary Committee will send a bill for a vote by the entire Senate sometime in September.

The College's Board of Regents feels that this legislation will be detrimental for both patients and physicians. In fact, it's difficult to recall any other proposed legislation that has had so much potential to harm patients. What can internists do?

Sen. Hatch asked ACP-ASIM to help the Judiciary Committee change the language of the bill. We told him that we don't see how a few changes in statutory language can address our core concerns about the bill's danger to patients. As long as there is a chance of persuading Congress to drop the bill altogether, ACP-ASIM will hold firm. A slightly better version will still be bad law.

For now, we must talk to people in our community about the danger that this bill represents and urge them to speak to their representatives in Congress.

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