Doctors, nurses and hospice organizations have banded together to try to stop federal legislation that would undo Oregon's pioneering law making doctor-assisted suicide legal.
While many of them oppose the practice, they fear that the bill would unintentionally discourage doctors nationwide from prescribing adequate pain-control medication for the terminally ill.
The legislation, which was quietly put on the fast track by Republican leaders, is slated for floor action in both chambers later this month.
The timing is particularly galling to political and medical leaders in Oregon, who say that their law, which went into effect nine months ago, is working better than expected.
Few Oregonians are actually requesting and taking prescription drugs to kill themselves. But doctors are prescribing more morphine and other pain-killing drugs for terminally ill patients, a practice that they had hesitated to follow before the law was passed for fear that they would be charged with trying to hasten a patient's death.
"Our experience here in Oregon demonstrates that, far from making Oregon into a horrible place where people are committing euthanasia, the law has had a salutary effect on the doctor-patient relationship for terminally ill patients," said Mark Gibson, health policy advisor to Gov. John Kitzhaber.
Gibson noted that just 10 patients had received lethal prescriptions so far and that only eight had taken them. The other two patients died before they could use the medication.
But equally significant is that Oregon, which ranked 11th in the nation in morphine use before the law was passed in 1994, was among the top three states in 1995 and 1996. Morphine use nationwide doubled between 1995 and 1997.
More Oregonians are also seeking hospice care at the end of their lives. Hospice, a nationwide organization that specializes in pain relief for cancer patients, opposes physician-assisted suicide.
The legislation working its way through Congress would authorize the Drug Enforcement Administration specifically to investigate whether doctors are prescribing pain killers not just to alleviate suffering but to hasten death.
And if the DEA concluded that a doctor was trying to hasten death, the agency could revoke the doctor's license to prescribe such drugs, thus effectively ending his ability to practice.
The National Conference of Catholic Bishops and the National Right to Life Committee worked with the bill's sponsors, House Judiciary Committee Chairman Henry J. Hyde (R-Ill.) and Sen. Don Nickles (R-Okla.), to draft the legislative language.
The Catholic Church, among the most vocal opponents of assisted suicide, has long seen the Oregon law as providing a slippery slope toward nationwide use of the practice, particularly with today's emphasis on restraining health costs.
"We're trying to prevent the federal government from actively facilitating assisted suicide," said Richard Doerflinger of the National Conference of Catholic Bishops. "The institutionalization of this would pose a threat to very vulnerable people, especially the poor and marginal."
But the DEA's proposed new authority, according to the legislation's critics, would have a chilling effect everywhere on doctors who prescribe large doses of drugs for the purpose of alleviating pain.
Even the Catholic Health Assn., which supports the bill, asked its sponsors to differentiate between medication given to ameliorate pain that also happens to hasten death and medication given to cause death. The former is permissible, the group said, the latter is not.
The undertreatment of pain is a private nightmare that haunts the end of life for a startling number of patients, according to academic studies.
Severe shortness of breath, pain, delirium and vomiting are typical symptoms at the end of life that frequently can be controlled only by escalating doses of analgesic drugs, such as morphine. Yet it appears that doctors are reluctant to give such medications.
High on the list of reasons for physicians' reluctance are state and federal regulations (the DEA already regulates "controlled substances") that cause doctors to fear a knock at the door from a law enforcement official who could revoke their license to prescribe drugs.
In New York state's landmark 1994 report on assisted suicide, the authors cited a litany of studies suggesting that many people die in pain, despite the availability of effective analgesic drugs. One study found that, of nearly 900 physicians caring for cancer patients, 86% reported most patients were undermedicated for pain.
In a 1998 survey of New York doctors, 71% reported that they did not prescribe effective medication for cancer pain if such prescriptions would require them to use a special state-monitored prescription form, typically used for such pain medications.
According to a University of Wisconsin study, physicians in that state reduce drug doses because of their fear of regulatory scrutiny.
"This [federal] legislation has enormous unintended consequences," said Thomas Reardon, a Portland, Ore., general practitioner and president-elect of the American Medical Assn.
"Under this bill, anyone can file a complaint against a doctor and then the DEA can knock on your door, come into your office, look through your records," Reardon said.
Oregon's congressional delegation is split, with Democrats opposing the legislation and at least one Republican searching for a way to vote against assisted suicide without undermining pain treatment.
"I don't want to discourage in any way experimentation in the relief of pain," said Sen. Gordon Smith (R-Ore.), who opposes assisted suicide.
A former Mormon bishop, Smith has experience ministering to the dying and helped write the law allowing Oregonians to write instructions refusing extraordinary measures to keep them alive.
"As a bishop I saw some of that pain and suffering and people whose lives were prolonged beyond any ability they had to have quality of life," Smith said.
Because of the outcry from the medical community, provisions have been added to the House version of the bill expressly providing that physicians would not be targeted if a patient died as a result of pain medication as long as the doctor had not intended to bring about the death.
Rep. Charles T. Canady (R-Fla.), a strong proponent of the bill, said it would "put into the law a recognition of the use of controlled substances in palliative care."
That is small comfort to many doctors.
"Physician-assisted suicide is always a last choice," said Salem, Ore., oncologist Peter Rasmussen. "But there are some people whose pain is so severe that the only way to make them comfortable is to give them so much medication that they sleep most of the time and have a clouded mind.
"But for some patients, to have their mental capacities blunted is worse than death, and they dread being in a zombie-like state. . . . And many patients take comfort in the idea that there is a way out."
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Since Oregon voters first approved doctor-assisted suicide in 1994, morphine use has soared not only in Oregon but also in California and around the nation. (Figures in grams per 100,000 population.)
Oregon California U.S. average 1992 1,481 908 984 1993 1,393 995 1,083 1994 1,398 1,002 1,098 1995 1,463 1,045 1,075 1996 2,011 1,394 1,297 1997 2,835 2,317 2,132
Source: Drug Enforcement Administration