"Pain Relief Promotion Act" Introduced

After long negotiations with hospice groups, congressional leaders are poised to break a year-long logjam over federal policy on assisted suicide.

Introduced June 17 by Representatives Henry Hyde (R-IL) and Bart Stupak (D-MI), the "Pain Relief Promotion Act" (H.R. 2260) already has 120 co-sponsors in the House of Representatives. An identical Senate bill (S. 1272), introduced June 24 by Senate Assistant Majority Leader Don Nickles (R-OK), has 15 co-sponsors, including Democratic Senator Joe Lieberman of Connecticut.

More striking is the list of groups endorsing the bill: Not only the National Conference of Catholic Bishops and National Right to Life Committee, but also National Hospice Organization, American Medical Association and American Academy of Pain Management. The latter groups had opposed the bill's predecessor, the "Lethal Drug Abuse Prevention Act of 1998," which was approved by House and Senate Judiciary committees last year but did not receive floor votes.

The old and new bills have an important aim in common: that of preventing federally controlled substances from being used to assist suicides in a state like Oregon that has legalized the practice. But medical groups said last year's bill could inadvertently have a "chilling effect" on physicians' ability to prescribe these drugs for legitimate pain control. As suggested by its new name, the Pain Relief Promotion Act is designed to have only a positive impact on efforts to relieve pain for dying patients.

Three differences between the bills stand out.

First, the 1998 bill responded to assisted suicides in Oregon by creating a new substantive policy against using federally regulated drugs for the practice in all 50 states. Critics said this policy would expand the authority of the Drug Enforcement Administration and could authorize a new level of scrutiny over physicians' pain management decisions in every state. The Pain Relief Promotion Act does not establish a new policy of this kind, but acknowledges what even U.S. attorney general Janet Reno conceded last year: that it is already against federal law to use controlled substances for assisted suicide in all states that have not acted to authorize the practice. The bill's only new policy on assisted suicide is that a state may not exempt itself from this pre-existing standard by passing a state law allowing assisted suicide [see June/July 1998 Life at Risk].

Second, last year's bill emphasized banning the use of controlled substances for assisted suicide, then conceded that this does not forbid their use for pain control. This year's bill reverses the emphasis: It affirms aggressive pain control as a legitimate purpose for use of federally regulated drugs, then explains that this does not authorize use for intentionally assisting suicides. The new bill also amends a provision on continuing education for law enforcement personnel, to provide for training in ways to accommodate physicians' legitimate use of drugs to control pain.

Third, the new bill amends current health care statutes to promote better understanding of pain control practices in federal programs, and to provide $25 million for grants to help train medical professionals in palliative care [see page 3].

When H.R. 2260 received a hearing in the House Judiciary Subcommittee on the Constitution on June 24, it was opposed by the Oregon Hospice Association, which treats assisted suicide as part of accepted medical practice, but was supported by the National Hospice Organization. While Senator Ron Wyden of Oregon still vows to use every possible tactic to block the new bill, the consensus now forged among pro-life groups and advocates for optimum palliative care may be unbeatable.

News Briefs

Oregon: In Trouble Again

As if new federal legislation against assisted suicide were not challenge enough [see page 1], Oregon's policies on end-of-life care came under renewed criticism in several forums this month:

• The federal Health Care Financing Administration has issued a report confirming that state officials have misappropriated $1,167 in federal funds to subsidize assisted suicides under Oregon's Medicaid plan. Such use of federal funds is barred under the Assisted Suicide Funding Restriction Act of 1997, which requires any state program funding assisted suicides to be completely separate from federally funded health programs. In a June 4 report to House Commerce Committee Chairman Tom Bliley (R-VA), HCFA says Oregon must reimburse the funds and should institute reforms to prevent such violations in the future [Associated Press, 6/8/99].
  
  
• The May-June issue of the journal The Hastings Center Report includes an extensive critique of the Oregon Health Division's report on the state's first year of legalized assisted suicide. Psychiatrist Herbert Hendin and pain control expert Kathleen Foley argue that the state's inadequate and misleading data provide no real support for its claim "that assisted suicide is being carried out safely" under the new Oregon law. According to the authors, there has been little real inquiry into the reasons why patients chose assisted suicide; no assurance that they received real counseling on alternatives; and significant evidence that a number of patients were referred to biased physicians by suicide advocacy groups. Without better reporting and more independent scrutiny, they argue, "we will not learn much from the Oregon experience" [K. Foley and H. Hendin, "The Oregon Report: Don't Ask, Don't Tell," 29 Hastings Center Report 37-42 (May-June 1999)].
  
  
• Even the state's claim to leadership in pain control and end-of-life care has received a blow. In a survey conducted by Oregon Health Sciences University, 34 percent of Oregon families say their loved one was in moderate or severe pain during the last week of life. The authors of the study, titled "The Oregon Report Card: Improving the Care of the Dying," found that the state's leadership in medical use of morphine has not translated into ideal control of pain and other symptoms in many cases [The Oregonian, 6/30/99].

Summary of the Pain Relief Promotion Act of 1999
(S. 1272, H.R. 2260)

TITLE I: CONTROLLED SUBSTANCES ACT

Does not establish a new substantive policy against using controlled substances in assisted suicide or euthanasia, because Attorney General Janet Reno acknowledges that such a policy already exists in states which have not legalized such practices. Instead, clarifies legitimate use of these substances for pain control in all states, and negates the impact of a state law favoring assisted suicide on the existing federal standard.

Section 101: Reinforcing Existing Standard
Amends Section 303 of the Controlled Substances Act (21 USC §823), which lists factors to be taken into account when deciding whether to grant or deny a practitioner's federal registration to dispense or distribute controlled substances for medical purposes. A new subsection (I) is inserted at the end of this section, providing that:

(1) alleviating pain and discomfort is a legitimate medical purpose for the use of controlled substances, even in the rare case where such use may increase the risk of death (principle of double effect), but nothing in this section authorizes use of such drugs for assisted suicide or euthanasia;

(2) a state's passage of a law authorizing assisted suicide or euthanasia has no force or effect in determining whether a practitioner has violated the "public interest" standard in this federal Act;

(3) paragraph (2) applies only to conduct occurring after the date of enactment of this Act.

Section 102: Education and Training

Amends the Controlled Substances Act's current provision on continuing education for local, state and federal law enforcement personnel, to educate these personnel in the necessary and legitimate use of controlled substances in pain management and palliative care, and means by which investigation and enforcement actions may accommodate such use. This education is to incorporate recommendations by the Secretary of Health and Human Services to ensure that it is based on the best current medical knowledge.


TITLE II: PROMOTING PALLIATIVE CARE

Gives new responsibilities to the Agency for Health Care Policy and Research (AHCPR) and Health Resources and Services Administration (HRSA), to promote better understanding of and expanded training in palliative care.

Section 201: Agency for Health Care Policy and Research
Instructs AHCPR to (1) develop and advance scientific understanding of palliative care, and (2) collect and disseminate information on protocols and evidenced based practices for optimum palliative care, emphasizing pain management for terminally ill patients. Such information shall be shared with public and private health programs, health professions schools, hospices and the public. Here and in the following section, "palliative care" is defined in language taken from the World Health Organization and the British government: It involves the active total care of patients whose prognosis is limited due to progressive, far-advanced disease; its purpose is to alleviate pain and other distressing symptoms and to enhance the quality of life, not to postpone or hasten death.

Section 202: Health Resources and Services Administration
Creates a new section in Title VII of the Public Health Service Act, to subsidize training programs in palliative care for health professionals, students in health professions schools, hospices, and other public and private entities. Such training is to include education in the medically and legally appropriate use of controlled substances to control pain, and recent developments in the provision of palliative care. Provides for evaluation of programs to determine the most effective means for improving knowledge and practice. Peer review groups which assist in determining allocation of these funds are to include one or more persons with expertise and experience in palliative care. To support such training, funding for these HRSA programs is increased by $5 million a year for the next five years.

Background: Support for the Pain Relief Promotion Act

House version (H.R. 2260) was introduced June 17 by Rep. Henry Hyde (R-IL) and Bart Stupak (D-MI); now has total of 120 sponsors (20 Democrats). Referred concurrently to Judiciary and Commerce committees.

Senate version (S. 1272) was introduced June 24 by Sen. Don Nickles (R-OK) and Joe Lieberman (D-CT); now has total of 16 sponsors (1 Democrat). Referred to Health, Education, Labor and Pensions Committee.

Supporting organizations:
American Medical Association
Christian Medical and Dental Society
National Hospice Organization
Hope Hospice and Palliative Care (Florida)
Hospice Association of America
Aging with Dignity
Physicians for Compassionate Care
American Academy of Pain Management
American Society of Anesthesiologists
Americans for Integrity in Palliative Care
National Conference of Catholic Bishops
National Right to Life Committee

Individual endorsements:
Dr. Walter Hunter, Vista Hospice
Dr. Ira Byock, Palliative Care Service (Montana)
Dr. C. Everett Koop, former U.S. surgeon general
Dr. Herbert Hendin, Director of American Foundation for Suicide Prevention
Dr. Ralph Miech, professor of pharmacology, Brown University
Dr. Edmund Pellegrino, Georgetown University

Sample comments:

"Your legislation would provide a mechanism for health care professionals to collect, review and disseminate vital practice protocols and effective pain management techniques within the health care community and the public. In addition, increased educational efforts focused within the health professions community about the nature and practice of palliative care are important components of your initiative."

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