Prop. 161--A Matter of Life or Death at the Polling Place : Initiative: If approved, the measure would make California the first place in the world where doctors are authorized to end lives of patients who request it. It has been the subject of a lively political struggle.

The strange, legalistic argument was over one of the most highly charged words in the English language.

Suicide .

Opponents of Proposition 161--the initiative legalizing physician-assisted suicide and euthanasia for certain dying patients--wanted to be sure the word appeared in the title and summary that voters see when they mark their ballots in November.

“No word better describes what this initiative is about than suicide ,” opposition attorney Thomas H. Hiltachk wrote in a letter to Atty. Gen. Dan Lungren, whose staff prepares the ballot language for all initiatives.

An author of the initiative, attorney Robert L. Risley, responded sharply: “Mr. Hiltachk seems fascinated by the word suicide and wants to use it to mislead the public.”

In the end, Risley won the argument. There is no mention of suicide in the title. And the brief ballot summary points out that the initiative declares that “physician-assisted death” is “not suicide.”

“We feel the ballot language is worth a million bucks to us,” said Jack Nicholl, campaign director for the yes-on-161 group Californians Against Human Suffering.

Whatever its impact, the ballot-title fight is typical of the clash over Propostion 161. It is more than a battle of words; the two sides are locked in combat over one of the most emotional issues to be placed on a state ballot.

If voters approve Proposition 161 on Nov. 3, California will become the first place in the world with a law specifically authorizing doctors to end the lives of terminal patients who request it or to provide those patients with the means to commit suicide.

Joining the opposition campaign--which is financed largely by Catholic organizations and even church collections--are a number of doctor, nurse and hospital associations, the American Cancer Society and the state Republican Party.

Leading the proponents is Risley, a downtown Los Angeles attorney, and his onetime law partner, Michael H. White. Risley has been trying to change state law since 1984, when his wife, Darlene, died of cancer.

Backing the two attorneys are the American Civil Liberities Union, the National Organization for Women of California and the Hemlock Society, an organization dedicated to legalizing physician-assisted suicide for the terminally ill.

Opponents contend that, based on close reading of the provisions, even those who support voluntary euthanasia should reject Proposition 161.

“We believe there are not enough safeguards,” said Gayle Ensign, who chairs the No on 161 campaign committee and is president of the California Assn. of Catholic Hospitals.

The opposition radio advertising puts the matter even more bluntly: “If this passes, people could actually be put to death by mistake!”

Specifically, opponents complain that the initiative has no requirement that witnesses be present when a patient requests help in dying or when the procedure is actually carried out.

At the very least, the opponents say, the initiative should spell out a reasonable waiting period between a patient’s first request for help in dying and the carrying out of that request.

The authors respond that current law does not require witnesses to be present when doctors “pull the plug”--the so-called passive form of euthanasia that is already legal in California--and they see no reason to require that in the initiative.

Risley said that the measure was drafted in a way that allows patients to maintain their dignity when they die.”There are rights of privacy here,” he said.

The two camps agree that Proposition 161 cannot be understood without looking at present state law, which began to change 16 years ago--at the same time that the family of a 21-year-old New Jersey woman, Karen Ann Quinlan, fought a successful battle to disconnect her respirator.

Today, mentally competent adults in California have a clearly defined right to refuse all treatment. For those who, like Quinlan, cannot speak for themselves and have not put their wishes in writing, family members, guardians or other surrogates can make decisions on their behalf. And that can include removing tubes that provide an unconscious patient with water and nutrition.

“The public doesn’t understand that they already have the right to refuse medical treatment,” said No on 161’s Bayley. Once that’s understood, voters will reject the initiative, she predicted.

However, supporters say that a full understanding of current law will, in fact, help their cause.

“We have decided that it’s OK if a physician turns off a respirator,” said initiative co-author White, an Encino attorney. “I see no morally significant difference if the doctor uses modern technology to end life quickly.”

White and Risley contend that the safeguards in their initiative are even more stringent in some respects than those that apply to “pulling the plug.”

The ballot measure states that:

* Those who want a doctor’s help in ending their lives must sign a directive stating their intentions. The document must be signed by two witnesses unrelated to the patient--family members and health care workers are not allowed. For patients in nursing homes, one of the witnesses must be a state-appointed ombudsman.

* A doctor may administer a lethal chemical or prescribe a fatal dose of drugs, but only if another physician also certifies that the patient has an incurable or irreversible condition and is likely to die within six months.

* Patients who wish to die must make “an enduring request” to end their lives “on more than one occasion.” The initiative does not demand a waiting period between requests. Physicians may suggest a psychological examination to determine a patient’s competence, but the patient need not agree. The initiative does not allow a patient to delegate the decision to anyone else.

* Doctors, nurses and hospitals may not be prosecuted or sued if they comply with the terms of the initiative. No doctors, nurses or private hospitals are required to participate if they prefer not to help patients die. Public hospitals, such as government-funded county and university facilities, may have to comply with a patient request.

* Insurance companies may not discriminate against those who have signed aid-in-dying directives.

* Annual reports must be filed with the state Department of Health Services on all physician-assisted deaths, but the names of patients will be kept confidential.

The opposition objects that Proposition 161 lets any licensed doctor play the role of executioner--even someone who has limited contact with a patient. When Washington state voters considered--and rejected--a similar measure last year, opponents argued, “Even an ophthalmologist (eye specialist) could give you a fatal injection.”

Opponents also argue that even the most experienced of physicians cannot predict with certainty that a patient will die within six months.

“In my personal practice, several patients rose from the dead and went home from the hospital,” said Dr. Henry R. Greene, a Pasadena cancer specialist and outspoken critic of the initiative. “None of them were cured, but they had months of good life.”

The initiative does not define what techniques will be used to end the life of terminal patients--other than to specify “a medical procedure that will terminate the life of the qualified patient in a painless, humane and dignified manner.”

Opponents argue that there is no accepted medical procedure for killing patients.

Proponents point to formal guidelines for “pulling the plug”--such as those developed by the Los Angeles County Medical and Bar associations that spell out in detail the obligations of physicians when forgoing or withdrawing life support. Similar proposals will set the standards for what procedures to follow for physician aid in dying, they said.

However, Susan Harris, vice chairwoman of the No on 161 campaign, worries that there will be no time to develop guidelines if the initiative passes. “The medical community does not know what the standard is,” she said.

Greene and other opponents said that 95% of terminal patients can be kept comfortable through aggressive use of pain medication. Hospice care allows the patients to be treated at home and retain a sense of control of their lives, Greene said.

The co-authors of Proposition 161 have no quarrel with the need for improved care for dying patients.

“We agree,” said White. “If there is better management of pain and hospice care, there will be less need for aid in dying.

“The opposition believes that there is a deep moral and ethical presumption against taking affirmative steps to help someone die,” he said. “I’d argue that even if people are morally opposed to this, they should still vote in favor of 161. The law should permit a person to make this decision with his doctor.”