GOOD NEWS FOR PATIENTS WHO SUFFER

A doctor is disciplined for undertreating pain in the terminally ill.
Dr. Paul Bilder may never become a famous name in the history of
end-of-life care at the end of the millennium.

Bilder is no Jack Kevorkian, the pathologist who brazenly defied the
law and forced the country to deal with assisted suicide. Nor is he
Timothy Quill, the internist whose published admission that he helped
a terminal patient to die encouraged other doctors out of the closet.

But Dr. Bilder represents a landmark nevertheless. This month, the
Oregon pulmonary specialist became the first doctor in the country to
be disciplined by a state board of medical examiners for undertreating
pain in his patients.

The patients in his "care" were not all dying, but some experienced
the kind of suffering that could have been alleviated -- and wasn't.
Once, Bilder prescribed only Tylenol for a terminally ill man with
cancer. Another time, he gave a patient only a fraction of the drug
that the patient needed and the hospice nurse suggested. He refused
morphine or similar pain medication for an 82-year-old with congestive
heart failure.

After being challenged on this mistreatment, Dr. Bilder signed an
order admitting that he showed unprofessional or dishonorable conduct
and negligence. For pain treatment and his skills at talking with patients.

It's not a surprise that the first such case in which a doctor is
taken to task for undermedicating pain and suffering happened in
Oregon. The state was, after all, also the first in the country to
pass a law legalizing doctor-assisted suicide.

Even those who deeply oppose such legislation acknowledge the good
news about the ethical wrangling over the end of life. We have finally
embarked on a long delayed discussion about the need for palliative
care, for compassionate treatment, for understanding the real
experience of illness.

Indeed in the same week that Dr. Bilder was disciplined for failing
his patients, the British medical journal Lancet published a Canadian
study showing that, even among terminal cancer patients, the will to
live fluctuates a great deal. In the course of just one day, attitudes
toward living and dying change. This research shows what common sense
suggests: Physical pain affects attitudes about living and dying.

Yet even in Oregon, as a recent study from the Center for Ethics in
Healthcare showed, a third of people in the last week of life suffer
moderate to severe pain. If pain is behind despair, if pain is the
primary rationale for supporters of doctor-assisted suicide, how much
of the ethical debate is really a medication debate?

The irony is that this controversy about pain and medicine has also
gone on and on. Twenty years ago doctors were penalized for giving too
much medication -- specifically narcotics.

For a long time, our paranoia about drugs and addiction, especially
narcotics, has affected the fear and freedom that doctors have to ease
pain. We have acted as if a terminally ill 80-year-old patient were a
junkie about to rise from her death bed and rob a grocery store. We
still deny marijuana for AIDS and chemo patients. We deny heroin to
the dying.

The health community is gradually adopting standards that recognize a
right to pain management. Nineteen states now have laws that protect
doctors from prosecution for prescribing painkillers as long as they
are used to kill pain. Oregon has, at last, stated that good care
means reducing suffering.

In the end, the most important part of Dr. Bilder's "punishment"
requires him to learn how to listen to patients. In the midst of an
ongoing national debate about a doctor's role in providing a
compassionate death, what he'll hear is the desire for just plain
compassion.