DOCTORS WARY OF BILL'S CURBS ON PAIN RELIEF

If Congress approves a measure prohibiting doctors from prescribing lethal
doses of controlled substances, dying patients will need to make room for
another chair at the bedside for the drug-enforcement agent, Northwest
doctors warn.

"It basically gives the Department of Justice the ability to decide what is
good medical care and what is not," said Dr. Richard Kincade, president of
the Oregon Medical Association (OMA). "That, to us, is unacceptable."

The Pain Relief Promotion Act of 1999 received substantial support in
Congress before lawmakers broke for their August recess. The American
Medical Association and the National Hospice Organization both support the
bill.

But leaders of both the OMA and the Washington State Medical Association
(WSMA) say they believe the bill will have a "chilling effect" on doctors'
willingness to prescribe adequate pain-relieving medication for terminally
ill patients.

The Oregon doctors have opposed the bill. And while the Washington State
Medical Association hasn't taken an official stance, WSMA leaders of the
association say they have no doubt its members overwhelmingly oppose it,
based on prior positions against government intrusion in the doctor-patient
relationship.

Some dying patients have "very severe pain" in their final weeks or days,
said Dr. Sam Cullison a family-practice physician from Seattle who serves on
WSMA's executive committee. That organization opposes assisted suicide.

"We know as physicians that the proper amount of pain relief in those
circumstances is whatever amount is required to relieve the pain," Cullison
said. "After the fact, is someone from the (federal Drug Enforcement
Administration) going to look at the chart and discern whether the
pancreatic cancer is the cause of death or the pain-relief medication? Are
they going to decide whether pain-relief medications hastened death - and to
what extent? Is it a second? A minute?"

These are areas in which there is great disagreement among medical
professionals, said Cullison.

"Our leadership has no confidence that the DEA could sort out those gray
areas," he said. "We'll have to add another chair to every hospital room so
there's a place for the DEA agent to sit and watch everything that the
physician is doing."

Sponsors of the bill, which include U.S. Sen. Don Nickles, R-Okla., and
House Judiciary Chairman Henry Hyde, R-Ill., have said they have no
intention of going after doctors.

The AMA's legal consultants have indicated they believe doctors aren't in
danger from the bill.

The newest version notes that pain relief is a "legitimate medical purpose"
for administering a controlled substance, "even if the use of such a
substance may increase the risk of death."

But the proposed law also adds: "Nothing in this section authorizes
intentionally dispensing, distributing, or administering a controlled
substance for the purpose of causing death or assisting another person in
causing death."

Kincade, the Oregon Medical Association president, said the OMA's legal
review of the bill concludes there isn't adequate protection for doctors who
use controlled substances for pain relief in terminally ill patients. The
OMA has been officially neutral on the issue of assisted suicide, Kincade
said.

This is an important issue in Oregon, Kincade said, where many physicians
read Oregon voters' decision to twice pass bills legalizing assisted suicide
as a negative commentary on doctors' ability to manage such pain.

After a years-long educational campaign, doctors there began to use morphine
and other pain-relieving medications more freely, Kincade said. In 1996,
Oregon led the nation in per capita medical use of morphine. Now, many
doctors are particularly sensitive to pain control in end-of-life care, he
said.

"We are really fearful that physicians will back off on adequate amounts of
pain control with controlled substances in end-of-life care," said Kincade.

Many Northwest doctors see the measure as a thinly disguised attempt to do
away with assisted suicide. Only Oregon has passed a law allowing physicians
to assist with suicides. But elsewhere, some doctors now believe that they
are legally safe providing doses of pain medication that ultimately result
in a patient's death, so long as the doctor's primary intention was to
relieve pain.

The bill's sponsors have denied the legislation is an attempt to overturn
Oregon's law, noting that there are other substances that can be used for
physician-assisted suicide.

But assisted-suicide supporters are not convinced. They point to a section
of the bill noting that state laws authorizing assisted suicide shall be
given "no force and effect."

"The intent of this bill is to eliminate use of controlled substances in
assisted suicide," Kincade said. There is no question, he added, that the
bill's larger goal is to eliminate assisted suicide completely.

"The act will shut down Oregon's law," predicted Michael Bonacci, executive
director of Compassion in Dying of Washington, which supports dying patients
and their families.