PAINKILLERS DETERRING SUICIDES

LOS ANGELES -- After years of national debate on the issue of
doctor-assisted suicide, fewer and fewer physicians are cooperating with
terminally ill patients who request help in ending their lives.

Surveys show that this is due in part to greater concern among some doctors
because of the public focus on the issue, but also because of a greater
emphasis on controlling pain in terminally ill people.

A growing number of doctors say that improved pain control techniques can
make the end of life relatively comfortable for dying people and thus
dissuade them from trying to take their own lives.

A study released last week on the first year of Oregon's new law allowing
physician-assisted suicide showed that few terminally ill people, just 15,
opted to end their lives with drugs provided by their doctors.

This pleased supporters of the year-old Death With Dignity Act, who said
the events of the first year under the new law showed that giving people
the ability to end their lives in strictly controlled conditions had not
led to a rash of suicides.

According to a membership survey by the American Society of Clinical
Oncology, support for doctor-assisted suicide and euthanasia among cancer
specialists declined by more than 50 percent during the last three years.

Only 22 percent of those questioned said they favored helping terminally
ill patients in constant pain end their lives, compared with 45 percent in
a similar survey in 1995. A similar survey published in the New England
Journal of Medicine in 1998 showed that while 18 percent of physicians
surveyed said they had been asked by patients to help them end their lives,
only 6 percent had acceded to those requests.

The oncologist survey also pointed to a problem many experts believe is
central to the care of people suffering from severe and persistent pain,
namely the problems related to the education of doctors in palliative care
and fears among physicians that prescribing large doses of morphine and
other opiates over long periods of time could place them in legal jeopardy.

A group at the University of Wisconsin Medical School is working to raise
awareness among physicians about dealing with pain in both the dying and
people who suffer chronic pain, often from maladies that are not clearly
diagnosed. Along with medical officials, the group is working to clarify
the rules that govern the prescription of strong pain-killing drugs.

The Federation of State Medical Boards of the United States recently issued
more flexible guidelines giving doctors greater leeway in using large doses
of morphine and related drugs over long periods of time.

"Pain should be assessed and treated properly and the quantity and
frequency of doses should be adjusted according to the intensity and the
duration of the pain," the new guidelines said, adding that it should be
clear that the sustained use of opiates can lead to physical dependence.

The guidelines, which are meant to be used as models for individual state
medical boards, also say, "Physicians should not fear disciplinary action
from the board or other state regulatory or enforcement agency for
prescribing, dispensing, or administering controlled substances, including
opioid analgesics, for a legitimate purpose and in the usual course of
professional practice."

"This is really groundbreaking," said Aaron Gilson, a researcher with the
Pain and Policy Studies Group at the University of Wisconsin. "What we
believe is that if more effective pain relief is provided, fewer patients
will opt to end their suffering by taking their lives."

Victor Kovner, a Los Angeles physician who has been involved with hospice
care for the last 15 years, echoed that statement. "Patients who have their
pain and other symptoms controlled are less likely to request suicide than
those who have unrelieved pain," said Kovner.

Gilson said the studies under way were looking beyond the use of drugs to
control pain among those in the final stages of cancer and other diseases.
"It is starting to extend beyond the terminally ill to people who suffer
chronic pain. Chronic pain has been inadequately treated," Gilson said.

The Wisconsin group is also sponsoring an Internet discussion of issues
surrounding the use of opioid drugs, primarily morphine, to control pain.

According to doctors who participated in the discussion, large doses of
morphine rarely hasten the death of individuals who have been taking
progressively increased doses of the drug.

"It is very hard to overdose people in morphine if they have been on it for
a while," said Joanne Mortimer, an associate professor of medicine and
medical oncology at Washington University School of Medicine in St. Louis.

Morphine kills by depressing the respiratory system to the point where an
individual dies of asphyxiation. But when the drug is used to kill pain and
is administered in progressively larger doses, morphine effectively kills
pain without affecting breathing.

The discussion prompted by the University of Wisconsin group showed that
doctors were well aware that the appropriate use of painkillers, even
powerful medications like morphine, usually did not hasten death.

But morphine, even when administered progressively, is occasionally fatal.
Nonetheless, medical experts and ethicists say the drug should be available
freely to doctors as a tool to treat pain.

If death came as a foreseeable, but unintended consequence of administering
the drug, there should be no legal or ethical problem for the physician
involved. This is the so-called ethical "principle of double effect."

"If pain control hastens death, it is an unintended side effect and is not
an ethical problem," said Timothy Murphy, a professor of medical ethics at
the University of Illinois at Chicago.