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The XX Files - 1.25.06

Live and let die?


Live and let die?

Let's hope the Bush administration got the hint last week. Finally someone --- the Supreme Court, specifically --- took it to task for overstepping its bounds. The Court, in a 6-3 ruling, pulled the plug on the administration's program of siccing the Drug Enforcement Agency on Oregon doctors who help terminally ill patients die. Since Oregon voters approved the Death with Dignity Act a decade ago, 208 people have used the law to die. Religious conservatives, ignoring both individual and states' rights, have been gunning for the law ever since.

In 2001, in a sneaky workaround, former attorney general John Ashcroft applied the federal Controlled Substances Act (designed to reign in drug traffickers) to docs who prescribe pain medication to terminally ill patients. Surely the DEA has something better to do than charge into hospices shackling weary physicians and confiscating their little white prescription pads. Then again, it's probably a lot easier and safer than actually fighting the illegal drug trade, where drug dealers carry Glocks and the only lives they value are their own.

Last week's rather narrow ruling was about an overstepping administration meddling in state law. The larger debate about assisted suicide, however, touches on many factors such as pain management and, for disability rights activists, the fear that society could use the law for sinister ends.

To assisted-suicide advocates like Timothy Quill, director of the Palliative Care Program at the University of Rochester Medical Center, the ruling was a relief.

"The most important thing," he says, "is if the decision had gone the other way, it would have empowered the Drug Enforcement Agency to get involved in end-of-life decisions, and that would have been terrible." Quill says the DEA's job is important, but it's not their business to be second-guessing doctors.

Oregon's assisted-suicide law --- the only one of its kind in the country --- is considered "open," meaning decisions are made with the knowledge of two doctors who must agree that the seriously ill patient is of sound mind, not depressed, and has fewer than six months to live.

But for Quill, this case is not just about the right to die. It's also about pain management. A ruling in the federal government's favor might have stopped some of the practices of assisted suicide, Quill says. "But it would have had huge unintended consequences in terms of under-managing pain."

If you've ever been to a doctor (or are just married to one), you know they're notoriously chintzy with pain medications. In addition, they tend to underestimate the pain you'll experience during a procedure. When I hear a doctor --- or my husband --- say, "you may experience some mild discomfort," I start popping Tylenol with codeine.

But I never knew the doctors' side of the story until Quill explained that when dealing with painkillers, doctors are very cautious, fearful of being investigated for over-prescribing. This fear has a chilling effect on pain management.

At the end of life, however, abuse of painkillers is typically not a major concern, Quill says. Comforting the dying person is. Because excruciating pain can compound the fear and anguish of a dying person, it's important that doctors feel safe prescribing strong pain killers.

Quill offers an example. "Some people at the end of life require large amounts of pain medication as part of their care," he says. "Some medications may even prolong life. Imagine an inexperienced DEA agent who sees a patient on increased amounts of pain medication and that patient dies. There may be a misinterpretation that the pain medication caused the death."

For Chris Hilderbrant, director of advocacy at Rochester's Center for Disability Rights, and for many disability rights groups, the idea of assisted suicide is terrifying in a society which they see as valuing money over human lives.

"What's particularly dangerous now is there's already a blame put on our community for the cost of Medicaid," Hilderbrant says. He worries that there is already a perception that, as he puts it, "'you people are a burden on the taxpayer.'"

"Take that and expand it, and see that people who are a burden and who are also suffering can choose to end their suffering and reduce the burden on society," he says.

And Hilderbrant recalls a letter to the editor in the Democrat and Chronicle a few years ago that said once people turn 75, they should receive no life-sustaining care. "There is an attitude out there that doesn't value our lives very highly," says Hilderbrant.

If you've ever fought to get coverage for a procedure or medication, you know our health-care system is all about profit. What if society opted for the $35-$50 lethal medication used in assisted suicides rather than pay thousands of dollars for long-term medical care? This dark view is put forth by Marilyn Golden, policy analyst for the Disability Rights Education and Defense Fund, who cites studies drawing correlations between for-profit managed care and pressure on physicians to offer assisted suicide.

For his part, U of R physician Timothy Quill says it's all about having sympathy for patients who, at the end of life, are not just in terrible pain but are "tired of dying, of feeling out of control." It's hard to imagine him supporting a system that administered lethal drugs to people who really don't want to die. But then, in a country where the federal government freely removes hard-fought individual and state rights, someone else might.