After passionate debate, the AMA House of Delegates voted last month to uphold AMA support for federal legislation opposing the prescription of controlled drugs for assisting in a patient’s suicide while vowing to press legislators for refinements that would better protect physicians who prescribe such drugs for palliative care.

The vote at the AMA’s interim meeting in San Diego last month followed hours of emotional debate in the AMA’s Reference Committee on Legislation (see below). Dozens of physicians rose in committee to speak on AMA support for the Pain Relief Promotion Act of 1999 (PRPA), S. 1272, with opinion evenly divided. The AMA Section Council on Psychiatry opposed the AMA position. APA delegate and section council member John McIntyre, M.D., told the reference committee to urge the AMA to work for changes in the PRPA to better protect physicians without suggesting that the AMA withdraw support for the bill.

(In the AMA governance process, delegates meet in numerous reference committees that are assigned resolutions to be voted on by the full House of Delegates. Only after the reference committees have considered the issues are they brought before the house for action.

The debate stemmed from division over the AMA’s support of S. 1272, which will be considered this year, and a companion bill, H.R. 2260, which passed by a vote of 271 to 156 last October. The law would uphold a Drug Enforcement Administration (DEA) ruling that prescribing controlled drugs to assist suicide is a violation of the federal Controlled Substances Act (CSA), the law empowering the DEA to regulate physicians’ prescribing of addictive drugs. The 1998 version of the bill, the Lethal Drug Abuse Prevention Act of 1998, was introduced that year after Attorney General Janet Reno overruled the DEA by holding that the CSA does not prohibit prescribing addictive drugs to assist suicide where physician-assisted suicide is legal under state law. Both the 1998 bill and the 1999 version would overturn Reno’s interpretation and bar any future attorney general from invoking that ruling. The bill does not address the prescribing of nonaddictive drugs for assisting suicide.

Oregon is the only state where physician-assisted suicide is legal, and Oregon Senator Ron Wyden (D) has vowed to filibuster the measure. But according to Congressional Quarterly Weekly (November 27, 1999), Majority Whip Don Nickles (R-Okla.), who sponsored S. 1272, has expressed confidence that he will be able to garner the 60 votes needed to limit debate and pass the bill this year.

During the reference committee debate, AMA President Thomas Reardon, M.D., reminded delegates that in 1995 the House of Delegates voted without dissent to oppose assisted suicide on ethical grounds. The AMA opposed the 1998 legislation, said Reardon, because it could have had a "chilling effect" on prescribing for palliative care. But the changes in the 1999 version "recognize the aggressive use of pain medication" as appropriate medical practice and further recognize that appropriate, aggressive pain management "may hasten death," he added. The latter concept, long endorsed by the AMA, is referred to as "the double effect."

The PRPA is "a Trojan horse," remarked Philipp Lippe, M.D., executive medical director of the American Academy of Pain Medicine, speaking for the 6000-member Pain Care Coalition. "It looks like a gift from the outside, but it is a destructive, violent force on the inside."

The bill, he continued, "invites the DEA into my office and into my mind to see what my intent is in giving controlled substances at the end of life to a patient who already is terminal."

Whether or not it really expands DEA authority is unclear, said Lippe, but "the perception of our doctors is that it does. And that perception is reality, and this has a tremendously chilling effect" on physicians’ prescribing of controlled substances.

Gregory Hamilton, M.D., an Oregon psychiatrist who campaigned against Oregon’s assisted-suicide law, said the PRPA "provides new protections for doctors by writing into law what has been true in medicine all along: that aggressive pain management is appropriate care even if it may unintentionally sometimes increase the risk of death."

Hamilton said the PRPA would not create any new authority for the DEA and would not address "how you and I practice medicine."

James Guest, executive director of the American Pain Foundation, a patient advocacy group, spoke in opposition to the PRPA. "I think nobody can say for sure how this legislation is going to be interpreted and how it is going to be implemented," said Guest. Although it may not give DEA new statutory authority, "what this law clearly does do is single out a particular part of medicine, palliative care and pain management, in statute, for special attention by the DEA," he stressed.

As approved by the House of Delegates, the resolution specified that the AMA continue to support the PRPA 1999 but added that "henceforth our AMA will oppose any future legislation [that] gives the federal government the responsibility to define appropriate medical practice and regulate such practice through the use of criminal penalties." —R.B.K.