Reality Check on the Pain Relief Promotion Act
Opponents of the Pain Relief Promotion Act claim that by preventing use of federally controlled drugs for assisted suicide, while encouraging their use for pain management, this Act could have a "chilling effect" on pain control.
This charge of a "chilling effect" runs contrary to all evidence. State and federal laws distinguishing assisted suicide from pain control have had universally positive effects on pain management [see Installment #2 in this series]. Moreover, it is the failure to draw a clear difference between the two that has a "chilling effect" on pain management and palliative care:
- A study in the October 3 Annals of Internal Medicine reports that support for assisted suicide among oncologists has halved in four years (from 46% to 23%). But the cancer experts least likely to have performed assisted suicide or euthanasia were also more reluctant to increase the morphine dose for patients with excruciating pain. They did not understand the ethical and legal difference between aggressive pain management and assisted suicide -- or they thought others would not understand it -- and so they were reluctant to practice effective pain relief. The authors comment: "This view may be encouraged by proponents of euthanasia who have argued that there is no difference between increasing narcotics for pain relief and euthanasia."
- In April 1997, the New York State Task Force on Life and the Law urged people on all sides of the assisted suicide debate to keep these distinctions clear. Noting that "many physicians would sooner give up their allegiance to adequate pain control than their opposition to assisted suicide and euthanasia," the Task Force noted that "characterizing the provision of pain relief as a form of euthanasia may well lead to an increase in needless suffering at the end of life."
- Writing in the April 1998 Minnesota Law Review, Dr. Howard Brody likewise urged support for the "principle of double effect," clearly distinguishing intentional killing from the unintended shortening of life that may occur during aggressive pain management. While Dr. Brody himself does not oppose assisted suicide, he is aware that many or most physicians do. He says pain management can be best served by clearly distinguishing it from assisted suicide. "Clinicians must believe, to some degree, in a form of the principle of double effect in order to provide optimal symptom relief at the end of life.. A serious assault on the logic of the principle of double effect could do major violence to the (already reluctant and ill-informed) commitment of most physicians to the goals of palliative care and hospice."
- The same point has been made by national organizations committed to palliative care: Accepting assisted suicide as just another form of end-of-life care undermines genuine care for dying patients. As the National Hospice Organization (now the National Hospice and Palliative Care Organization) said in its "friend of the court" brief in the Supreme Court's 1997 assisted suicide cases, "the acceptance of assisted suicide as a way to deal with terminal illness would undercut further efforts to increase the public's awareness of hospice as a life-affirming option."
- The converse is also true: clearly rejecting assisted suicide is a benefit to palliative care. As the American Medical Association said in its brief in the Supreme Court cases, "the prohibition on physician-assisted suicide provides health care professionals with a tremendous incentive to improve and expand the availability of palliative care." Or as one hospice physician has said: "Only because I knew that I could not and would not kill my patients was I able to enter most fully and intimately into caring for them as they lay dying" (quoted by Dr. Leon Kass in "Why Doctors Must Not Kill," Commonweal, Sept. 1992, p. 9).
Experience has shown that these projections are correct: accepting assisted suicide alongside pain control undermines pain control.
- During oral arguments in the Supreme Court cases, Justice Stephen Breyer cited a British House of Lords report showing that acceptance of assisted suicide and euthanasia in the Netherlands has apparently led to the stagnation of hospice medicine: The Dutch operated only three hospices at the same time that Great Britain, which bans assisted suicide, had 185 of them.
- The same trend can be seen in Oregon. It ranked 3rd highest among the 50 states in per capita use of morphine for pain control in 1992, two years before Oregon voters voted to legalize assisted suicide; it ranked 6th in 1998, the first full year the new law was in effect. A major health insurance plan in the state has capped reimbursement for hospice care at $1000 per patient, while providing unlimited support for assisted suicide. And Oregon families' reports of moderate to severe pain among their dying hospitalized loved ones increased markedly (from 33% to 57%) in the last months of 1997, when the assisted suicide law took effect, and continued to be higher than previously throughout 1998 (Western Journal of Medicine, June 2000, pp. 374 ff.).
In short: Banning assisted suicide, or distinguishing it from aggressive pain management, does not have a "chilling effect" on pain control. Failing to do so has that effect.
Uninformed groups have asked why Congress can't keep these issues separate: Banning assisted suicide in one law, and promoting pain management in another. But this would produce two bad laws. One would ban assisted suicide without making it clear that pain management is not banned – and that would have a chilling effect on pain management. The other would endorse efforts to kill pain, without making it clear whether that can include killing the patient – and that would be irresponsible, and ultimately have a chilling effect on pain control as well.
By making the distinction clear, the Pain Relief Promotion Act serves optimum pain management.