[Moderator's Note: The following are letters to the editor contained in the most recent (April 6, 2000) edition of the New England Journal of Medicine in support of the Pain Relief Promotion Act. This pro-life legislation has been passed by the House of Reprsentatives and is currently pending in the Senate Judiciary Committee.]
We are writing in support of the Pain Relief Promotion Act of 1999 and to express reservations about your editorial in the December 16 issue.
(1) As hematologists and oncologists, we care for terminally ill patients. Our perspective is sharpened by the fact that one of us recently lost his father to metastatic carcinoma and that it was necessary to prescribe controlled substances as palliation in the final weeks of life.
A physician's task is to relieve suffering and protect life but never to end life. The Pain Relief Promotion Act is an attempt by Congress to restore equal protection to a vulnerable class of citizens in Oregon who lost this protection when the voters in that state decriminalized physician-assisted suicide. The will of Oregon voters on this particular matter must be thwarted. A law derives its legitimacy not only from the wishes of the majority of citizens but, primarily, from its consistency with basic ethical principles. Because intentional killing of innocent human beings is simply not ethical, it is also unethical to help them kill themselves. Whether such "help" involves the prescription of an overdose of a controlled substance or the provision of cyanide or a gun is immaterial.
More education for doctors is needed on the use of adequate doses of controlled substances in terminally ill patients, and such patients need reassurance that all possible resources to relieve pain will be marshaled by their physicians.
Nevertheless, a compassionate and ethical doctor never diverts attention from ministering to the living patient to hastening that person's death, no matter how challenging the problems.
Regarding your more overextended statements, it seems strange to refer to the effects of a law that protects life as "pernicious"; promote the right to use controlled substances to terminate life because some patients and physicians "often have exaggerated fears of addiction"; and characterize theological considerations as "toosimplistic," when in a pluralistic society all viewpoints should be considered with respect and our system of jurisprudence is strongly influenced by religious ethical principles. As it happens, the editorial's most disturbing and truly pernicious message is its endorsement of the notion that entities such as the "laboratory of the states" or even the Supreme Court are free to legalize practices that are intrinsically unjust. Other examples of legalized but clearly unethical practices would have to include anti-Semitic laws in Nazi Germany, Jim Crow laws in the United States, and quasilegal euthanasia in the Netherlands.
Oswaldo Castro, M.D.
Victor R. Gordeuk, M.D.
Fitzroy Dawkins, M.D.
Washington, DC 20059
1. Angell M. Caring for the dying -- Congressional mischief. N Engl J Med 1999;341:1923-5.
To the Editor:
You make two important mistakes in your editorial. You state that "the House of Representatives voted to amend the [Controlled Substances Act] to make it a federal crime, punishable by 20 years in prison, for doctors to prescribe drugs for terminally ill patients to end their lives." The Pain Relief Promotion Act of 1999 does not change the penalty for this shameful activity anywhere outside of Oregon. Even if this act does not become law, it will remain illegal in 49 states for a practitioner to prescribe a controlled substance with lethal intent.
You go on to state that the passage of the act would have a chilling effect, deterring doctors from providing adequate pain control to dying patients. This is a testable, indeed a tested, hypothesis. In the past few years, several states have passed legislation with the same effect as that of the Pain Relief Promotion Act. If such legislation truly had a chilling effect on the prescribing patterns of physicians, its passage should have been followed by a drop in per capita consumption of morphine in those states.
In fact, the opposite was observed. For example, in the spring of 1996, Louisiana passed a law that bans assisted suicide but allows methods of pain control that might unintentionally increase the risk of death. Per capita morphine consumption in Louisiana rose 80 percent that year and nearly tripled two years later. Similar results were seen when Rhode Island, Virginia, and Kansas passed similar laws. In fact, of the 10 states with the highest per capita morphine consumption, 7 have specific statutes against assisted suicide. It is true that Oregon's per capita morphine consumption is relatively high, but that is not because the state allows physician-assisted suicide. In the six months following Attorney General Janet Reno's ruling that the Drug Enforcement Administration would not punish physician-assisted suicide, per capita morphine consumption in Oregon was actually less than it had been in the preceding six months, when the alleged chilling effect of threatened federal sanctions was in effect. (1,2)
Yes, the states do provide a wonderful laboratory, but the experiments conducted there disprove your belief that laws like the Pain Relief Promotion Act deter good palliative care. The act would eliminate federal collusion in the nasty business of doctors' killing their patients, and it deserves our support.
Eric Chevlen, M.D.
St. Elizabeth Hospital
Youngstown, OH 44501
1. House of Representatives Report 106-378, part 1, page 13.
2. Congressional Record (for House of Representatives). October 27, 1999:H10894-H10895.