Maine Rejects Assisted Suicide; Congress Stalls

In an upset victory for opponents of assisted suicide, Maine voters on November 7 rejected the nation's latest "death with dignity" proposal modeled on Oregon's 1994 law.

In mid-September, a statewide poll by Strategic Marketing Services showed 72% of voters supporting the measure to legalize physician-assisted suicide or leaning in its favor [Bangor Daily News, 9/27/00]. However, after supporters and opponents each spent over a million dollars to educate voters, the measure was defeated by over 17,000 votes. The unofficial tally, with 99% of precincts counted, is 331,585 against the proposal and 314,199 in favor (51.3% to 48.7%).

In the final weeks of the campaign, proponents aired ads urging Mainers not to let "one church" decide this issue for them – a thinly veiled anti-Catholic ploy that was less effective in Maine than it has been in Oregon. While the Catholic Church was active in educating its members and in raising funds for the broader public campaign, it was joined in opposing the measure by state medical and hospice societies and other secular groups belonging to Maine Citizens Against the Dangers of Physician-Assisted Suicide.

When Oregon began debating its unique law allowing assisted suicide, proponents predicted that a victory there would lead similar laws to "sweep across the country" [Hemlock Quarterly, October 1993, p. 2]. Since 1994, however, ten states have passed new laws against assisted suicide, and legalization measures have been defeated in many more. In 1998, Michigan voters rejected a legalization measure 71% to 29%.

Despite this trend, legislation to prevent use of federally controlled drugs for assisted suicide – the Pain Relief Promotion Act of 2000 – remains stalled in the U.S. Senate.

The Act's chief opponent, Senator Ron Wyden of Oregon, agreed in late July that he "won't be unreasonable" in continuing to block its consideration if sponsors could show they had 60 votes for cloture, to end a threatened filibuster [The Oregonian, 7/28/00]. But he then persuaded the Senate's Democratic leaders to hold the bill hostage to a number of other measures. Even Democratic sponsors of the pain relief bill were urged by their party to say they would oppose cloture unless various unrelated bills of interest to Democrats could be offered as amendments [The Oregonian, 9/20]. A Republican offer to allow a floor vote on a "Violence Against Women Act" strongly supported by women's groups, in exchange for allowing a vote on the Pain Relief bill, was rejected by Democrats.

Due to this impasse, the pain relief bill's supporters have sought opportunities to attach the bill to one of the large spending bills that must be enacted before the end of this Congress. In late October, House Republicans reintroduced the Pain Relief Promotion Act with a new bill number (H.R. 5544) and attached it to a tax relief package containing provisions of interest to both parties. This package passed the House on October 26, but has stalled in the Senate under a veto threat from the White House. As Congress prepares for a brief post-election session in December, it is unclear whether the Pain Relief Promotion Act will be attached to a "must-pass" legislative vehicle to avoid Senator Wyden's delaying tactics.

President Clinton joined the debate on the pain relief bill on October 30, raising the question "whether the bill as written would have a chilling effect on doctors writing medication for pain relief on terminally ill patients" [The Oregonian, 10/31]. Supporters of the bill responded by releasing a study of ten states which have passed similar laws since 1992, showing that per capita use of morphine for pain relief increased an average of 51% in these states after enactment [see page 3].

News Briefs

Cancer Doctors Oppose Euthanasia

A survey of U.S. oncologists suggests that support for euthanasia and assisted suicide in this profession has declined dramatically in recent years.

The survey polled 3299 members of the American Society of Clinical Oncology in 1998. It found 22.5% support for physician-assisted suicide for a terminally ill patient with prostate cancer in unremitting pain, compared to 45.5% support in 1994. Euthanasia in this situation was supported by 6.5%, compared to 22.7% in 1994. Overall, 10.8% said they had ever performed assisted suicide and 3.7% said they had performed euthanasia.

Surgical oncologists were more likely to support these practices; Catholics, those who view themselves as religious, and those who say they have sufficient time to talk to dying patients about end-of-life care were less likely to do so.

Of concern to the authors is the finding that those who oppose euthanasia and assisted suicide are also less willing to increase the dose of morphine for a patient who has unremitting pain despite previous pain relief efforts. "This reticence," they note, "probably reflects fear that increasing opioid dose increases the risks for respiratory depression and death and might be construed as a form of euthanasia. This view may be encouraged by proponents of euthanasia who have argued that there is no difference between increasing morphine for pain relief and euthanasia." The authors urge increased efforts "to educate physicians on the ethical and legal acceptability of increasing narcotics for pain control, even at the risk of respiratory depression and death" [E. Emanuel et al., "Attitudes and Practices of U.S. Oncologists regarding Euthanasia and Physician-Assisted Suicide," 133 Annals of Internal Medicine (3 October 2000) 527-532 at 530].

Another recent study, however, suggests that many physicians support various degrees of physician involvement in lethal injection for capital punishment. A survey of 482 physicians, asking about eight practices disallowed by the American Medical Association (four of them involving some degree of involvement in lethal injections), found that 34% approved of all eight, 53% supported five or more practices, and 43% supported allowing physicians to inject the lethal drugs – "indicating that they believed it is acceptable in some circumstances for physicians to kill individuals against their wishes." Support for such killing was stronger among physicians who accept physician-assisted suicide [N. Farber et al., "Physicians' Attitudes About Involvement in Lethal Injection for Capital Punishment," 160 Archives of Internal Medicine (October 23, 2000) 2912-6].


Dutch Parliament "Legalizes" Euthanasia

By a vote of 104 to 40, the lower house of the Dutch Parliament on November 28 agreed to "legalize" euthanasia and assisted suicide – in fact only formalizing a policy established by court-made law over more than two decades. If approved by the Senate, which is considered a formality, the legislation will take effect next year [AP, 11/28/00].

The new law is likely to fuel, not reduce, the abuses now well documented in the Dutch system. Patients need not have a serious or terminal illness but only unremitting "suffering" to receive euthanasia, and can submit declarations of intent in advance, allowing physicians to decide whether and when to kill them when they are not mentally competent; prosecutors will no longer review all reported cases to detect abuses [CNN.com, 11/28].

In one recent court case, a Dutch physician was acquitted October 30 for assisting the suicide of 86-year-old E. Brongersma in 1998. Defense counsel said the patient, a former Dutch senator, had no physical or mental illness but "suffered from life itself." The Haarlem court found that the physician acted rightly because he consulted two other doctors who agreed that the patient's suffering was unbearable ["Dutch court allows physician-assisted suicide without a medical disorder," 356 The Lancet (November 11, 2000) at 1666].

Morphine Use in States Enacting Laws Like the Pain Relief Promotion Act

Since 1992 ten states have passed laws against intentionally assisting a suicide, incorporating language to affirm doctors' ability to provide pain relief even if it may unintentionally increase the risk of death (as in the federal Pain Relief Promotion Act). Changes in per capita use of morphine in these states (in grams per 100,000 people) were as follows. Morphine data are from the U.S. Drug Enforcement Administration.

Iowa - new ban took effect July 1996
1995 - 935 g - 30th among states
1996 - 1221 - 28th
1997 - 2207 - 26th
1998 - 2029 - 38th
Percentage change in morphine use (from year before enactment to year after): +136%

Kansas - law took effect July 1998, strengthening assisted suicide ban and adding positive provision on pain control
1997 - 2047 g - 35th
1998 - 2016 - 39th
1999 - 2179 - 32nd
2000 (first half, pro-rated) - 2311 - 31st
Percentage change in morphine use: +6%

Kentucky - new ban took effect July 1994
1993 - 1388 g - 11th
1994 - 1624 - 6th
1995 - 1462 - 4th
1996 - 1673 - 7th
Percentage change in morphine use: +5%

Louisiana - new ban took effect June 1995
1994 - 843 g - 41st
1995 - 786 - 45th
1996 - 1058 - 37th
1997 - 1845 - 42nd
Percentage change in morphine use: +26%

Maryland - new ban took effect October 1999
1998 - 2858 g - 16th
1999 - 2990 - 15th
2000 (first half, pro-rated) - 3347 - 12th
Percentage change in morphine use: +17%

Rhode Island - new ban took effect August 1996
1995 - 928 g - 33rd
1996 - 966 - 46th
1997 - 2454 - 18th
1998 - 2480 - 24th
Percentage change in morphine use: +164%

South Carolina - new ban took effect June 1998
1997 - 1457 g - 51st
1998 - 1625 - 49th
1999 - 1659 - 49th
2000 (first half, pro-rated) - 2014 - 43rd
Percentage change in morphine use: +14%

South Dakota - law took effect July 1997, strengthening assisted suicide ban and adding positive provision on pain control
1996 - 978 g - 45th
1997 - 2132 - 30th
1998 - 1896 - 43rd
1999 - 1880 - 43rd
Percentage change in morphine use: +94%

Tennessee - new ban took effect July 1993
1992 - 1180 g - 16th
1993 - 1417 - 9th
1994 - 1544 - 8th
1995 - 1407 - 7th
Percentage change in morphine use: +31%
(For first half of 2000, Tennessee ranks 2nd highest among states, with 2261 g of morphine per 100,000 people. Pro-rated for full year this would be 4522 g)

Virginia - new ban took effect April 1998
1997 - 2007 g - 37th
1998 - 2106 - 33rd
1999 - 2401 - 27th
2000 (first half, pro-rated) - 2432 - 28th
Percentage change in morphine use: +20%

Average percentage change in use of morphine for pain control in the ten states enacting new laws against assisted suicide, incorporating language on pain control similar to that of the proposed federal Pain Relief Promotion Act: +51%

Background: Ralph Nader on the Pain Relief Promotion Act

At an August 25 press conference in Portland, Oregon, Green Party presidential nominee Ralph Nader announced his support for the Pain Relief Promotion Act. Republican nominee George W. Bush also supports the Act; Democratic vice-presidential nominee Joe Lieberman is the bill's prime Democratic sponsor in the U.S. Senate. Excerpts of Mr. Nader's remarks follow.

"Oregon, I think, was the first initiative, referendum, recall state. I think it had a lot of progressive political reforms in the past... But in recent times the referendum has been used by a few rich people or certain interest groups that I don't think are in the progressive interest of Oregonians. And I'll jump into this one: physician assisted suicide.

"I don't think HMOs, employing physicians, and able to kill off someone who may be depressed or feels that she or he is a burden on their family, for $40, in order to increase the profits of the HMOs, should take advantage of any physician-assisted statute. And they are going to take advantage of it. We need support for the federal legislation that advances pain relief programs -- because we're not good in this country on pain relief practices -- and that supports new research in pain alleviation for people who may suddenly wish they want to die because of reasons of family, or reasons of enormous short-term depression caused by pain that could be alleviated."

(Question: As you may know, those are fighting words in Oregon. A lot of people don't want the federal government messing with an initiative twice approved by Oregon voters. Do you worry that some of your base in Oregon... may [because of your position on this issue] go for Gore instead?)

"I don't think the federal bill preempts, if you read it carefully, the Oregon referendum. I think it provides resources for doctors and others in pain relief, research in pain relief; and it does condition the use of controlled substances under the existing controlled substances law, if those controlled substances are used for physician- assisted suicide. But it does not preempt and throw out the Oregon referendum. I think people in Oregon voted for that largely because they saw it as a matter of choice instead of what it could well be: a matter of duty, or duress, or HMO cash, HMO profits. The right to die sometimes becomes a duty to die, a duress to die, under the influence of HMOs who aren't exactly adhering to the Hippocratic oath in the way they conduct their daily activities."...

(Question: Do you think this may cost you some votes, though, [among] some supporters?)

"I'd like to engage in some discussion with them, because I think the premise of choice is not really the reality for many people."

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