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By Richard Karel
The APA Ethics Committee has endorsed the AMA's opposition to a federal bill that would criminalize physicians who prescribe controlled substances to assist suicide.
The bill, the Lethal Drug Abuse Prevention Act of 1998, was sponsored by Rep. Henry Hyde (R-Ill.) in the House and Sen. Don Nickles (R-Okla.) in the Senate in response to Attorney General Janet Reno's decision this June overturning a Drug Enforcement Administration (DEA) ruling. The ruling overturned would have allowed the DEA to suspend or revoke a physician's controlled substances license if the agency could prove that controlled drugs were prescribed with the intent of assisting a suicide. The bill would give the DEA the authority it seeks. At press time a vote had not occurred.
The bill, H.R. 4006/S. 2151 (the respective House and Senate versions), would also create a medical review board to determine the physician's intent in prescribing potentially lethal controlled drugs. It is the question of letting the DEA determine intent that has galvanized the AMA and the APA Ethics Committee.
Principal Deputy Associate Attorney General Joseph Onek, J.D., testified against the bill for the Department of Justice. While reaffirming federal opposition to physician-assisted suicide, Onek observed that the bill would put the DEA "into the role of overseer of the practice of medicine." Further, said Onek, having the DEA determine whether a physician's prescribing was "an appropriate means to relieve pain" would "involve the DEA in issues in which it has no particular expertise."
Unlike the AMA, which is officially opposed to physician-assisted suicide, APA has never taken an official stance on that issue, observed APA past president Lawrence Hartmann, M.D., who sits on the APA Work Group to Educate Members on Physician-Assisted Suicide. The misconception that APA has an official position is based on APA's support in fall 1996 for an AMA amicus brief to the U.S. Supreme Court opposing assisted suicide, Hartmann explained (Psychiatric News, November 15, 1996). The high court ultimately found that although there is no right to physician-assisted suicide, the states may determine the legality of the practice for themselves.
When APA agreed to back the AMA amicus brief, APA also "explicitly said that APA had no official position on physician-assisted suicide" and that support for the brief should not be construed as constituting an official position, Hartmann told Psychiatric News. At that time, the APA Board of Trustees agreed that further debate and discussion were needed.
This spring, then president Herbert Sacks, M.D., appointed the work group on physician-assisted suicide, naming Area 4 Trustee Norman Clemens, M.D., chair. One of the members of the work group is also the current chair of APA's Ethics Committee, David Wahl, M.D.
"The APA Ethics Committee has debated [physician-assisted suicide] on a number of different occasions and has taken a very clear position in opposition," Wahl told Psychiatric News. "It is the view of the majority of members and consultants to the Ethics Committee that physician-assisted suicide is fundamentally incompatible with the physician's role and responsibility to the dying patient. Furthermore, the Ethics Committee has urged the Board of Trustees to consider a position consistent with [those of] both the Ethics Committee and the AMA."
Despite the absence of an official APA position on physician-assisted suicide, the Ethics Committee agrees with the AMA that the legislation is misguided, said Wahl. The bill "misses the point" and "attempts to get around the larger issue by addressing the motives and intent of the prescribing physician rather than fundamentally addressing the needs of the dying patient," said Wahl. "Setting up these sanctions may cause psychiatrists to pull further away from this already underserved group of patients. This kind of legislation would stigmatize the treatment of the dying patient and create greater barriers" to appropriate end-of-life care, Wahl added.
At present, only Oregon has officially legalized physician-assisted suicide, allowing physicians to assist passively by providing patients with medication and information about how to use the medication to end their lives. Since the Oregon Death With Dignity Act went into effect on October 27, 1997, only eight Oregonians are known to have used the law's provisions to end their lives, according to the Oregon Health Department. Two people received prescriptions but died prior to taking the medication. Half of those who received prescriptions were men, and the average age was 71; nine were cancer patients, with one heart disease patient. Nine physicians participated in writing the prescriptions. There were no complications. Most patients waited two days to use the drugs, and most patients died within 30 minutes, while one person slipped into a coma and died seven hours later.
In a poll conducted this summer by GLS Research of Los Angeles, 66 percent of a random sample of Americans said they would support a law similar to Oregon's Death With Dignity Act in their state, and 75 percent said they opposed any action by Congress to repeal Oregon's law. Nearly all respondents (93 percent) agreed that "physicians should be allowed to prescribe whatever medication they feel is necessary to alleviate the pain of terminally ill patients in their final days."
Linda Emanuel, M.D., Ph.D., is the AMA's vice president for ethics and the principal investigator for the AMA's End of Life Initiative.
The AMA's goal is to educate physicians and patients so that "patients feel there is no need to request physician-assisted suicide," said Emanuel. The DEA proposal "may hinder that goal rather than aid it, by making physicians reluctant to use adequate doses of controlled analgesics to control the physical suffering that often attends the end of life." Physicians "need to be engaged in an honest and open debate" about what must be done to provide adequate palliative care.
Emanuel said she has yet to see a case where proper use of medication failed to allay pain, and noted that it is possible to put a dying patient into an anesthetic coma if necessary to relieve suffering. While there are cases involving spiritual or psychological suffering, "it is not rationally defensible to argue for legalizing physician-assisted suicide in such cases" said Emanuel. "We should never lose sight of the fact that" the process of dying involves many forms of suffering, she added.
"Rather than doing something potentially punitive with federal law, we need to ensure universal access to care at the end of life," said Emanuel. "Nobody should die an undignified death for lack of medical care."
The AMA Web site dealing with end-of-life care is www.ama-assn.org/epec. The bills are viewable through thomas.loc.gov/home/thomas2.html or