SEPARATING DEATH FROM AGONY

BOSTON Not long ago, a cancer specialist I know faced a situation that
chilled those of us who care for people with terminal illness. A young
woman close to death lay suffering in a hospital bed, her husband at her
side. Her leukemia had defied bone marrow transplant and experimental
drugs. She had begun to bleed into her lungs and was gasping for air.

Months earlier, following common practice, the oncologist had had a frank
discussion about dying with the woman and her husband. The greatest terror
for her, as for most other patients, was that the final days of her life
might be spent in unrelenting pain. An understanding was reached among the
patient, the doctor and the family that if the time came when there was no
real hope of surviving and she faced only pain and debility, no
extraordinary means would be taken to sustain her and sufficient doses of
drugs like morphine would be administered to ease the pain, even if that
meant reducing her breathing or lowering her blood pressure and thereby
expediting her death.

That time had clearly come, but when the doctor ordered morphine, a
respiratory therapist at the bedside vehemently objected. He asserted that
the morphine, because it inhibited her breathing, was nothing more than a
thinly veiled disguise for physician-assisted patient suicide. The
patient's husband, aghast, reiterated the promise given to his wife. The
doctor was not deterred and prescribed as much morphine as was required to
alleviate the painful suffocation that occurs when the lungs fill with
blood. Within a day the young woman peacefully died.

The physician felt that he had fulfilled his moral and professional
obligation to relieve suffering, and the family was satisfied that their
loved one's death occurred with as much dignity as possible. But the
respiratory therapist then accused the physician of nothing less than a
crime, and the husband of being an accomplice. The charge was judged
unfounded first by a hospital review board and later by the district
attorney's office. Yet the step by Attorney General John Ashcroft this week
in response to Oregon's legalization of physician-assisted suicide could
have dictated a different outcome.

Mr. Ashcroft authorized the Drug Enforcement Administration to take
punitive action against physicians who prescribe lethal drugs for
terminally ill patients; the doctors' licenses would be suspended. This
action, which is being challenged by the state, represents a striking lack
of understanding of how physicians help patients to die, and it risks
making the last days of the terminally ill a time of panic and pain rather
than calm and comfort. While this legal policy may be directed at a single
state where patients can obtain prescriptions for the lethal drugs under
certain circumstances, Mr. Ashcroft endangers what has become a
compassionate, if tacit, mode of dying throughout the United States.

Nothing could be further from the truth than Mr. Ashcroft's statement that
a federal drug agency could readily discern the "important medical, ethical
and legal distinctions between intentionally causing a patient's death and
providing sufficient dosages of pain medication necessary to eliminate or
alleviate pain." In fact, it is medically impossible to dissociate
intentionally ameliorating a dying patient's agony from intentionally
shortening the time left to live.

In the case of the young woman with leukemia and pulmonary hemorrhage, the
doses of morphine needed to ease her suffering also depressed her
breathing. And death is rarely a gentle process of simply closing one's
eyes. Rather, there are potent physiological reflexes, graphically termed
"agonal." Narcotics like morphine are essential in dampening these death
throes, and in doing so, they facilitate death.

Mr. Ashcroft's action also threatens the very essence of the hospice care
that in recent years has allowed so many terminal patients to die at home,
with doctors and nurses easing the passage through the prudent use of pain
medications.

Some opponents of the attorney general invoke states' rights, arguing that
federal agencies should not meddle with Oregon's law. This skirts the more
fundamental issue. Helping nature take its course is not criminal, and it
should be outside governmental regulation. Decisions about when and how to
die are best left to patients, families and health professionals, not
legislators and litigators. Committees of doctors and nurses already exist
in hospitals and hospices that can exercise sound judgment in controversial
cases and advise on the parameters for the process of dying.

If the Justice Department's action is a political bone thrown to religious
conservatives, it shamefully miscasts health professionals as disciples of
the devil rather than angels of mercy. If it represents an earnest attempt
to protect the dying, it in fact makes them more vulnerable. Death will
ultimately come, but without the skilled hands of physicians and nurses to
ease the release of the soul.