AMA Maintains Support for Pain Relief Act

Despite a months-long campaign, opponents of the federal Pain Relief Promotion Act (H.R. 2260, S. 1272) failed in December to end the American Medical Association's support for the measure.

In October, the Rhode Island Medical Society (RIMS) wrote to Congress urging opposition to the Act. RIMS said its letter was co-signed by nine other state medical societies. On October 19, members of Oregon's House delegation told their colleagues that the number of state societies opposing the Act was "12 and growing." But when House members contacted these societies they found that several supported the bill.

In November, the Oregon Medical Association debated a resolution urging the AMA to oppose the Act. Even in Oregon, however, this resolution was controversial, and was amended to ask only that the AMA "reconsider" its stand. The Medical Society of New Jersey tabled a similar resolution.

When the AMA's semi-annual House of Delegates meeting convened in San Diego in December, three state societies (Oregon, Rhode Island and North Carolina) and one specialty society, American Academy of Family Physicians (AAFP), had submitted resolutions urging the AMA to reconsider or reverse its stand.

A hearing on the resolutions was held December 5 by an AMA reference committee on legislation chaired by Dr. Cathy O. Blight of the Michigan State Medical Society. While opponents of the Act offered emotional testimony claiming it would have adverse effects on pain control and medical practice, supporters focused on factual evidence. Physicians for Compassionate Care, representing over a thousand physicians in Oregon and other states who oppose assisted suicide, distributed hundreds of briefing books explaining the Act. PCC president Dr. N. Gregory Hamilton presented evidence that use of pain control drugs has increased in states that ban assisted suicide while affirming the legitimacy of pain relief -- especially in Rhode Island, where morphine use more than doubled after passage of the state's ban.

Other supportive witnesses included: Dr. Barbara Rockett, past president of Massachusetts Medical Society, who assured her Rhode Island colleagues that most AMA delegates from New England support the Act; and Dr. Robert Orr of Loma Linda University, who that morning had received a prestigious AMA award for "Leadership in Medical Ethics and Professionalism."

The reference committee's final report rebutted key charges against the Act and recommended continued AMA support [see page 4]. On December 8 the House of Delegates approved the committee's substitute resolution, albeit with changes offered by the AAFP.

The final resolution does not declare a stand on the Act, but leaves in place the AMA's supportive stance. It recommends changing two provisions of the bill: a provision on continuing education for law enforcement personnel, and one calling on the Department of Health and Human Services to disseminate guidelines on pain control. The AAFP had claimed these provisions involve the federal government too closely in determining what is "legitimate" pain control. But the delegates defeated a proposal that the AMA would drop its support of the Act if these provisions are not changed.

A strong editorial promoting the Act in a recent issue of the AMA's newspaper suggests that opponents' campaign backfired: the national organization's support is now more resolute and firmly based on a thorough study of the issue ["A better end," American Medical News, Jan. 3-10, 2000, p. 17]. The Senate Judiciary Committee is expected to consider the bill early in the new year.

News Briefs

Suicide Activists Explore New Methods
Faced with the likelihood of a ban on use of federally regulated drugs for assisted suicide [see page 1], euthanasia activists are sharing new ideas on other means for killing oneself.

Meeting in Seattle on November 13, an ad hoc alliance of activists from various countries called "The NuTech Group" (short for The Self-Deliverance NuTechnologies Group) unveiled devices for delivering deadly gas or facilitating suffocation. One device receiving a great deal of attention used scuba gear. "We've been working with diving experts on this because they know all about sudden death," says Derek Humphry, whose Euthanasia Research & Guidance Organization (ERGO) sponsored the conference. Compassion in Dying and the Death with Dignity Legal Defense and Education Center did not attend, saying they prefer to work within the legal system [The Oregonian, 11/12/99 and 11/14].

Handgun Purchase as a Risk for Suicide

Evidence grows that access to lethal means increases people's risk of suicide. In the November 18 New England Journal of Medicine, researchers report that "the purchase of a handgun is associated with a substantial increase in the risk of suicide by firearm and by any method."

The study compares rates and causes of death for adults in California with those for adults who purchased handguns from licensed firearms dealers in the state in 1991. "Suicide by any method was the leading cause of death among handgun purchasers in the first year after handgun purchase," accounting for 24.5% of deaths (compared with 1.7% of deaths for all Californians). The increase in suicide risk was especially marked among women, who generally use guns far less frequently for suicide than men. After adjusting for age and sex, handgun purchasers were still at a four times greater risk of suicide than other adults in the first year after the purchase. Female purchasers also had a higher risk of homicide, while male purchasers were at slightly lower risk.

The researchers also review past studies showing an increased risk of suicide when people have access to lethal means. "In New York City," they note, "where handgun ownership has been strictly regulated since the early 20th century, rates of suicide are very low; rates of suicide by other methods vary directly with the availability of those methods." While "right-to-die" groups say access to a suicide method can prolong life, by assuring the person that a quick "exit" is at hand if needed, the data run counter to that claim [G.J. Wintemute et al., "Mortality Among Recent Purchasers of Handguns," 341 New Eng. J. Med. 1583-9 (11/18/99)].

Dutch OK suicide for patient with dementia

A Dutch physician who assisted the suicide of a patient with dementia has gone without prosecution after publicizing her action in a Dutch medical journal.

The 71-year-old male patient had suffered from dementia for four years, and wanted to die before his mental condition deteriorated further. A psychiatric exam found him "ill enough not to want to go on anymore, but...not so demented that he could not decide." The psychiatric hospital in charge of his care then allowed his physician to give him a lethal dose of barbiturates for suicide.

The Alzheimer's Foundation in the Netherlands reacted to the case by warning: "Dementia itself could never be a reason for assisted suicide because the patient is incapable of making an informed request." But a spokesperson for the Royal Dutch Medical Association says assisted suicide may be appropriate for a "competent" patient with early dementia [T. Sheldon, "Euthanasia endorsed in Dutch patient with dementia," 319 British Medical Journal 75 (10 July 1999)].

A recent case involving the assisted suicide of an elderly woman with dementia has also stirred protests and debate in Oregon [Sept./Oct. 1999 Life at Risk, p. 2; D. Reinhard, "In the dark shadows of Measure 16," The Oregonian, 10/31/99].

Senator Nickles on the Pain Relief Promotion Act
VERBATIM: On November 18, prime Senate sponsor Don Nickles (R-OK) entered into the Congressional Record an authoritative explanation of the intended scope and effect of the proposed Pain Relief Promotion Act (S 1272). Excerpts follow:

To hear some of the critics of this bill you might think that the Pain Relief Promotion Act creates a new authority on the part of the DEA to revoke doctors' registrations if they use controlled substances to assist suicide. On the contrary that authority has existed for 29 years and it exists now. Attorney General Janet Reno was very clear on this matter in her letter of June 5, 1998: "Adverse action under the CSA may well be warranted... where a physician assists in a suicide in a state that has not authorized the practice under any conditions, or where a physician fails to comply with state procedures in doing so."...

How does the Pain Relief Promotion Act impact this situation? It establishes that, for the first time in federal law, the use of controlled substances for the relief of pain and discomfort is a "legitimate medi-cal purpose," even if the large doses used in treating pain may unintentionally hasten death. Intentionally causing death or assisting in causing death remains forbidden. Thus this bill does not increase the DEA's regulatory authority at all. On the contrary, its only effect in 49 states (and even in Oregon, in cases involving those who are not terminally ill) is to provide new legal protection for physicians who prescribe controlled substances to control pain.

In Oregon, this bill eliminates the Attorney General's artificial exception designed to accommodate assisted suicides that are no longer penalized under Oregon law. The DEA can meet its responsibility here simply by looking at the reports required by Oregon law... Those records will make it clear whether federally controlled drugs were used; and since the physician is clearly reporting that his or her own intent was to help cause death, there will be no question of murky intentions or ambiguity. Thus this bill will not lead to any increase in the DEA trying to "second guess" or infer physicians' intentions, even in Oregon.

What of any unreported cases in which physicians assist the suicides of terminally ill patients? Those assisted suicides are already a crime under Oregon law, and thus already subject to adverse action by the DEA as well under the Attorney General's interpretation. Only if a physician officially reports the case to the Oregon Health Division is he or she exempted from state criminal penalties. So those cases are already covered by the same DEA authority that currently applies to assisted suicides in the other 49 states.

Let me take this situation step by step... First, removing the Oregon exception to the existing nationwide policy cannot increase any "chilling effect" on pain relief outside of Oregon, because the bill does not increase one iota the authority of the DEA to investigate the misuse of controlled sub-stances to assist suicide outside of Oregon. In fact, in those states its only effect is to provide a more explicit "safe harbor" for the practice of pain control, which is a significant advance and improvement for doctors and terminally ill patients. This is also true of assisted suicide cases within Oregon that do not comply with the state's reporting requirements or other guidelines. In all these cases, the Pain Relief Promotion Act gives the DEA no new mandate to investigate cases of assisted suicide more directly. Rather, it is expected to follow its longstanding practice of generally deferring to state authorities and allowing them to take the lead in investigating possible wrongdoing.

Second, no new questioning of physicians' intentions is warranted to address the cases of assisted suicide that are now permitted under Oregon law. To be free of criminal penalties under state law in Oregon, a doctor who assists a suicide must submit a report to Oregon authorities that includes information on the drugs prescribed to assist the suicide. The Drug Enforcement Administration, DEA, can obtain those reports from the Oregon authorities... Thus, even in Oregon, this bill will not result in any increase in DEA oversight or investigations of doctors based on their prescribing patterns or the dosages they use for particular patients... It follows that if this bill is enacted, any doctors in Oregon who prescribe controlled substances for pain relief need not fear any increase in DEA scrutiny of their practices, and therefore should not in any way be deterred from prescribing adequate pain relief.

Background: AMA Committee on Pain Relief Promotion Act

At the American Medical Association's semi-annualHouse of Delegates meeting in San Diego, a Reference Committee addressing legislative issues heard testimony December 5 on whether to change the AMA's stance supporting the Pain Relief Promotion Act (H.R. 2260, S. 1272). Excerpts from the committee's final report follow.

Despite differing opinions about the bill's content, there appeared to be near consensus among the speakers at the Reference Committee that physician-assisted suicide is not an acceptable medical practice and that every effort should be made through proactive legislation or other means to encourage the rendering of effective and compassionate palliative and end-of-life care to all patients in need of such...

Turning to the actual bill and existing law, the majority of testimony centered on several major issues including the scope of DEA authority, the need to oppose the criminalization of medical practice, and promoting, while not hindering, state palliative and end-of-life care guidelines...

In the spirit of moving forward in a positive manner and with the recognition that the substantial weight of testimony argued in favor of continued support for the "Pain Relief Promotion Act of 1999," your Reference Committee urges the adoption of the substitute resolution based on the facts presented at the hearing, including:

First, your Reference Committee agrees with the bill's sponsors that the "Pain Relief Promotion Act of 1999" would for the first time establish in federal law substantial new protections for physicians prescribing controlled substances in the ordinary course of patient treatment. This position is substantiated by a Department of Justice letter dated October 19, 1999, wherein it is affirmatively stated that "H.R. 2260 would eliminate any ambiguity about the legality of using controlled substances to alleviate the pain and suffering of the terminally ill by reducing any perceived threat of administrative and criminal sanctions in this context. The Department accordingly supports those portions of H.R. 2260 addressing palliative care."

Second, because the bill would amend existing statutory law in the Controlled Substances Act, in existence for decades, the suggestion that the bill would extend DEA authority or create new penalties, although passionately stated, is without legal merit. The bill would do neither of these things by a "plain meaning" reading of its language. Instead, it would legislatively acknowledge the legitimate medical purpose of prescribing controlled substances, even if one effect were ultimately to cause death, the so-called "double effect." This intent has been confirmed by debate on the House floor relating to the bill, as well as in a comprehensive Congressional Record statement by Senator Nickles. As it currently stands, physicians are potentially susceptible to DEA scrutiny any time they prescribe controlled substances. This new bill would truncate this authority, but retain DEA authority to investigate instances where controlled substances are used to effectuate a physician-assisted suicide.

Finally, your Reference Committee finds without legal merit allegations that state palliative care guidelines would be overridden by [the Act], or that the DEA would have any new authority to promulgate federal guidelines under this bill.

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