The more compelling arguments for physician-assisted suicide — about avoiding great pain and suffering — do not seem to be motivating requests for physician-assisted suicide in Oregon. Based on current evidence, people seeking physician-assisted suicide there are more often concerned about loss of autonomy and control. We question whether it is medicine's role to give patients control over the timing and manner of death.

This finding is supported by a report from the Oregon Health Division's Fifth Annual Report on Oregon's Death with Dignity Act, indicating that the dominant reasons for requesting physician-assisted suicide were loss of autonomy (84%), decreasing ability to participate in activities that make life enjoyable (84%), and losing control of bodily functions (47%).

Federal Law
The federal government has also tried to address this issue. The Pain Relief Promotion Act passed the House of Representatives in 2000, but was not brought to a vote in the Senate. The bill promoted pain management and palliative care through the education and training of health care providers. It also banned dispensing federally-controlled drugs with the intent to assist in a patient's suicide. It provided a safe haven for physicians who dispense pain control medications in accordance with the federal Controlled Substance Act.

Paradoxically, some physicians and even some health-related organizations opposed the legislation, despite its specific language protecting providers who prescribe medications for pain relief. The strategy for convincing legislators that a bill promoting pain relief would actually do the opposite and impede pain relief is laid out in some detail in a book entitled Handbook of Pain Relief in Older Adults, to be released by Humana Press later this year. Advocates of physician-assisted suicide and euthanasia knew that support for their agenda was thin, both in the medical community and in the general public. Seniors, a rapidly growing political force, are particularly leery of measures that may appear to be incremental steps toward arbitrarily limiting life. There is, of course, overwhelming support for providing pain relief for those who are suffering. Therefore opposition to the legislation, could not be based on opposition to pain control or support for assisted suicide, instead, doubts had to be raised about the effectiveness of the bill in advancing pain control.

Opponents therefore broadcast their "fears" that physicians would misunderstand the bill, that this would have a "chilling effect" on physicians prescribing medication for pain, and, thus, that pain relief efforts would be impeded. Ultimately the strategy was effective and even persuaded some well-recognized experts in palliative care to oppose the Pain Relief Promotion Act.

When a bill bans physician-assisted suicide but affirms and protects physicians using controlled drugs for pain management, does that have a chilling effect on patient care? Experience with state legislation shows the opposite is true. Maryland, for example, banned physician-assisted suicide in 1999. Now that the law has been in effect for a few years it is clear that such legislation has not had a "chilling effect" on pharmaceutical prescribing. To the contrary, Drug Enforcement Administration records from 1992-2000 show that in Maryland, as in every state that passed a similar law in that time period, there has been an increase in the per capita use of opioids, like morphine, used for pain control (see figure 1). When physicians attending lectures I've given on pain management throughout the country learn about these protections for prescribers, they react with a mixture of relief and elation that such legislation exists.

Opponents of a ban on physician-assisted suicide continue to raise the issue of its supposed "chilling effect" on pain management, but they carefully avoid reference to the accumulating evidence against this argument in state after state. Their other arguments — for example, that physicians fear government intervention and oversight, or that assisted suicide is a "states' rights" issue — are specious. The real agenda of many groups organized against bans on physician-assisted suicide is to promote legalized euthanasia. They fear that banning assisted suicide will hurt their cause, whereas allowing it will be an incremental step toward their goal of permitting active euthanasia.

The Federal Courts
In 1997, the U.S. Supreme Court ruled that state laws that criminalize physician-assisted suicide are not unconstitutional. That ruling did not make physician-assisted suicide a crime. It simply declared that criminalizing physician-assisted suicide is a matter that each state may decide for itself.

But the court will likely consider the issue again. In November 2001, U. S. Attorney General John Ashcroft issued a directive entitled "Dispensing of Controlled Substances to Assist Suicide" (the "Ashcroft Directive"). The directive concludes that assisted suicide is not "a legitimate medical purpose" for drugs controlled by the federal government under the Controlled Substances Act. Under the directive, doctors who use these drugs to assist suicide are subject to having their federal narcotics prescribing licenses suspended or revoked.

Opponents of the directive have again raised the unfounded fear of a "chilling effect" on pain relief. They claim the directive will undo years of work spent in overcoming apprehension about addiction and securing adequate pain relief for patients. In April 2002, U.S. District Judge Robert Jones permanently restrained the Ashcroft Directive, stating that the U.S. Attorney General had "overstepped the authority of the federal Controlled Substances Act when he declared that physician-assisted suicide was not a ‘legitimate medical purpose.'" The Attorney General has appealed Judge Jones' decision and the case is pending before the 9th Circuit Court of Appeals as of this writing.

The role of physicians
The nation's largest medical specialty organization and second-largest physician group, the American College of Physicians, has officially announced its opposition to physician-assisted suicide as a matter of principle. It has also expressed concerns about effectively regulating the practice and protecting vulnerable populations, as well as the potential for abuse. The College continues to be concerned about research showing that physicians and other clinicians are often not well trained in end of life care. If physician-assisted suicide were to be accepted as standard practice, the College believes it would undermine the physician-patient relationship as well as improvements in end of life care.

The nation's largest medical group, the American Medical Association (AMA), has taken a similar stance, stating that allowing physicians to participate in assisted suicide would cause more harm than good. The AMA maintains that physician-assisted suicide is fundamentally incompatible with the physician's role as healer, would be difficult or impossible to control, and would pose serious societal risks. The American Medical Association's 156-year-old Code of Medical Ethics prohibits physician-assisted suicide in the same strong language it uses to prohibit physician involvement in euthanasia.

Legalizing physician-assisted suicide would bring subtle and not-so-subtle pressure to bear on terminally ill patients who fear their illness is physically, emotionally, or financially burdensome to families or caretakers. The legal option to commit suicide with a physician's help would be perceived as an obligation by many terminally ill patients concerned about being a burden to loved ones — patients who might not otherwise have considered suicide at all.

Instead of participating in assisted suicide, physicians should respond aggressively to the needs of patients at the end of life. The American Medical Association affirms that patients should not be abandoned simply because a cure may be impossible, as now happens too often. Multidisciplinary interventions should be sought, including specialty consultation, hospice care, spiritual support, family counseling and other assistance. Patients near the end of life deserve to receive emotional support, comfort care, adequate pain control, respect for patient autonomy, and good communication.

For physicians, the issue transcends state legislation. Doctors must not be forced to participate in physician-assisted suicide, abortion, capital punishment or other practices that run counter to professional ethics or personal beliefs. And physician-assisted suicide raises other medical dilemmas as well. My own research and many other studies demonstrate that accurate diagnosis and prognosis cannot always be assured. For some patients who died from physician-assisted suicide, subsequent autopsies revealed that they did not have a terminal illness! The impact such an error has on survivors (not to mention the patient) can only be imagined.

Distinguishing between actively ending a life and allowing the natural progression of events is an integral part of discussions of physician-assisted suicide. Honoring a person's wishes regarding burdensome interventions, such as cardiopulmonary resuscitation (CPR) or ventilatory support neither hastens death nor prolongs life. In such situations, the public often has a misconception of the impact of some medical interventions. Our inability to extend life or even to predict our ability to do so is far different from the impression one might get from watching prime-time television. Oftentimes medical interventions may actually cause more suffering and even unintentionally hasten death. Reviews of the evidence on the use of feeding tubes and CPR in frail older adults have made this abundantly clear. What is important in providing care at the end of life is that physicians maintain the patient-physician relationship no matter what course the patient finally chooses, short of participating in suicide. Withdrawing or withholding treatments, e.g. respirators, CPR, and even hydration or nutrition at the request of a terminally ill patient or the patient's surrogate can be consistent with professional principles and are supported by the American Medical Association's Code of Medical Ethics.

There is, of course, a final reason to advocate for physician-assisted suicide. It is cheaper to kill a person than to provide care. Yet a physician's first obligation is to "Do No Harm." Until that is replaced with "Save more money," it will be difficult to support physician-assisted suicide.

Dr. Gloth is Associate Professor of Medicine at Johns Hopkins University School of Medicine and president of Victory Springs Senior Health Associates, Inc. He is the former President of the Hospice Network of Maryland and is Board Certified in Hospice and Palliative Medicine. Dr. Gloth currently serves as the Associate Medical Director for Carroll Hospice in Maryland.

Program Models
Sign up to be a RESPITE volunteer! RESPITE, supported by The National Family Caregiver Support Program, provides assistance to the primary family caregiver, by providing supplementary care arrangements for the dependent relative on a needed basis. This may include care in the home, an adult day-care center, or a weekend in a nursing home or assisted living facility. The National Council of Catholic Women produces resources to aid volunteers: RESPITE Manual, 2nd Edition, $11.95; RESPITE Video, $24.95 (purchase), $8.00 (loan); brochure, $0.25 each (10-99 copies); Information for Caregivers brochure, $0.25 each (10-99 copies); RESPITE pin $4.00. Call NCCW's national office at 202-682-00334, ext. 108 to order your materials.

Become a Parish Nurse — The parish nurse focuses on the spiritual, emotional and physical dimensions of persons, in their parish, as they strive to achieve wellness and to manage their illness. They function as an educator, a counselor, a referral agent and an advocate. There are currently over 6,000 parish nurses throughout the United Sates. Marquette University College of Nursing hosts an institute open to registered nurses with several years of experience to take part in an eight day educational program. This institute is held in various locations around the country. The second phase of this institute is a nine-month optional program offering five seminars and ongoing support to the nurse. Contact the Marquette University College of Nursing at nursing@marquette.edu, or at (414) 288-3809.

Start a YOUNG AT HEART group for the senior citizen community in your parish. This group can be used for fellowship and social events. Plan short trips, special Masses, or meals out at a local restaurant.

Begin a Bereavement group in your parish to work one-on-one with church members who have lost a loved one. Set up a system to assign a volunteer to meet with the bereaved parishioner for one year after the death of a loved one. Skills needed: compassionate, caring, loving and a good listener.

Pray for the sick of your parish. Begin a prayer chain or if you already have one invite others to join to pray for those who are in the hospital or terminally ill. Prepare meals for the family, allowing them to spend more time with their loved one.

Plan now! Speak with your family and medical doctor about your wishes for your health care, should you become unable to make these decisions.

Resources
Teaching Documents
The Dignity of Dying People. Pontifical Academy for Life, 1999. Reprinted in Origins, Vol. 28, No. 41 ($2.95 to download).

The Gospel of Life. Pope John Paul II, 1995. Washington, D.C.: USCCB. Also in Spanish ($7.95).

Declaration on Euthanasia. Sacred Congregation for the Doctrine of the Faith, 1980. Available from Secretariat for Pro-Life Activities (50 cents).

Guidelines for Legislation on Life-Sustaining Treatment. NCCB Committee for Pro-Life Activities, 1984. Secretariat for Pro-Life Activities (60 cents).

In the Service of Life. Pontifical Council for the Family, 1992. Washington, D.C.: USCCB ($1.25).

Nutrition and Hydration: Moral and Pastoral Reflections. NCCB Committee for Pro-Life Activities, 1992. Secretariat for Pro-Life Activities ($1.95).

On the Christian Meaning of Human Suffering. Pope John Paul II, 1984. Washington, D.C.: USCCB ($3.95).

Statement on Euthanasia. NCCB Administrative Committee, 1991. Secretariat for Pro-Life Activities ($7/100; $65/1,000).

Print
A Catholic Guide to End-of-Life Decisions. Brighton, Mass.: The National Catholic Bioethics Center, 1998 ($2; quantity discounts).

The Case against Assisted Suicide: For the Right to End-of-Life Care. Kathleen Foley, M.D. and Herbert Hendin, M.D. (eds). Baltimore: The Johns Hopkins University Press, 2002 ($49.95)

Dying Well: The Prospect for Growth at the End of Life. Ira Byock, M.D. New York: G.P. Putnam's Sons/Riverhead Books, 1997 ($24.95).

Euthanasia and Physician Assisted Suicide: Killing or Caring? Rev. Michael Manning, M.D. Mahwah, N.J.: Paulist Press, 1998 ($8.95).

Euthanasia Examined: Ethical, Clinical and Legal Perspectives. John Keown (ed). Cambridge, England: Cambridge University Press, 1995. ($24.95).

Forced Exit. Wesley J. Smith. New York: Random House, 1997 ($25).

Handbook for Mortals: Guidance for People Facing Serious Illness. Joanne Lynn, M.D. and Joan Harrold, M.D. New York: Oxford University Press, 1999 ($25).

Last Rites: Assisted Suicide and Euthanasia Debated. Michael M. Uhlmann (ed). Grand Rapids, Mich.: Wm. B. Eerdmans, 1998 ($35).

Lessons from the School of Suffering: A Young Priest with Cancer Teaches us how to Live. Rev. Jim Willig and Tammy Bundy. Cincinnati, Ohio: St. Anthony Messenger Press, 2001 ($6.95).

Life's Worth: The Case against Assisted Suicide. Arthur J. Dyck. Grand Rapids, Mich.: Wm. B. Eerdmans Publishing Co., 2002 ($20.00).

Living the Final Season. Kathy Kalina, RN, CRNH. Boston: Pauline Books & Media ($4.95).

Midwife for Souls: Spiritual Care for the Dying. Kathy Kalina, RN, CRNH. Boston: Pauline Books & Media, 1997 ($5.95).

Power over Pain: How to get the pain control you need. Eric M. Chevlen, M.D. and Wesley J. Smith. Steubenville, Ohio: International Task Force in Euthanasia, 2002 ($12.95).

Right to Die versus Sacredness of Life. Kalman J. Kaplan (ed.). Amityville, N.Y.: Baywood Publishing Co., 2000 ($31.95).

Stations of the Cross for the Sick. Catalina Ryan McDonough. Bloominton, In.: Our Sunday Visitor, Inc. ($4.95) May be ordered from www.osv.com.

When Death Is Sought: Assisted Suicide and Euthanasia in the Medical Context. Report of the New York State Task Force on Life and the Law (updated, 1999). Albany, NY: Health Education Services ($10).

Newsletters, Pamphlets, Reprints
Life at Risk. Acclaimed bimonthly newsletter tracks euthanasia trends in America. USCCB Secretariat for Pro-Life Activities (free; donations gratefully accepted).

Euthanasia. . .When the Doctor Kills the Patient. John Willke, M.D., pamphlet. Cincinnati: Hayes Pub. ($15/100; $65/500).

The Gift of Life ...in the Face of Death. Secretariat for Pro-Life Activities, 1998, pamphlet ($9/100; $80/ 1,000).

Hope for the Journey: Meaningful Support for the Terminally Ill. Kathy Kalina, RN, CRNH. Secretariat for Pro-Life Activities, reprint, 2001 (#0101-KAL; 40 cents; 10-49 copies, 30 cents ea.; 50+ copies, 25 cents ea.).

Killing the Pain, Not the Patient: Palliative Care vs. Assisted Suicide. Richard M. Doerflinger & Carlos Gomez, M.D. Secretariat for Pro-Life Activities, reprint, 1998 (#9801-DOE; 40 cents; 10-49 copies, 30 cents ea., 50+ copies, 25 cents ea).

In Support of Life: Comfort and Hope for the Dying. Brochure. Massachusetts Catholic Conference (50 cents; quantity discounts).

Oregon's Assisted Suicide Experience: Safeguards Don't Work. Oregon Right to Life. Salem, Ore.: Omega Publications (25 cents; quantity discounts).

Audiovisual
Euthanasia: False Light. Steubenville, OH: Intl Anti-Euthanasia Task Force, 1995. Excellent discussion featuring physician, hospice nurse, and three patients who survived "terminal illness" ($24.95).

Final Blessing. Washington, D.C.: USCCB, 1997. Thought-provoking documentary on the spiritual dimensions of the lives of terminally ill persons ($29.95).

Life at Risk: A Closer Look at Assisted Suicide. Twelve audiotapes of 1997 symposium of international experts at Catholic University of America, co-sponsored by the NCCB, The Catholic University of America and the Center for Jewish and Christian Values. Available from Donehey & Associates ($50 per set in an album; individual tapes available at $5 ea.).

Physician Assisted Suicide: Not Worth Living? Colorado Springs: Focus on the Family/ Gospel Light ($20.00).

Internet
www.acponline.org/journals/news/sept98/suicide.htm (American College of Physicians)

www.ama-assn.org/ama/pub/category/8288.html (American Medical Assoc. Code of Ethics)

www.cathmed.org (Catholic Medical Assn.)

www.healthinaging.org/public_education/pain (American Geriatrics Society Foundation for Health in Aging)

www.iaetf.org (Intl. Anti-Euthanasia Task Force)

www.kofc.org/faith/cis/028/sacredlife.cfm (Knights of Columbus Catholic Information Service)

www.ncbcenter.org (Nat'1 Catholic Bioethics Center)

www.ncpd.org (Nat'l Catholic Office for Persons with Disabilities)

www.nrlc.org (Nat'l Right to Life Committee)

www.nursesforlife.org (Nat'l Assn. of Pro-Life Nurses)

www.seniorhealthcare.org (Senior Health Care Organization)

www.stemcellresearch.org (Coalition of Americans for Research Ethics)

www.usccb.org/prolife

__________________________
Secretariat for Pro-Life Activities
United States Conference of Catholic Bishops
3211 4th Street, N.E., Washington, DC 20017-1194 (202) 541-3070