First: Care at the end of life is complex; reform will take time and sustained attention; and enduring improvement requires innovation and investment through Medicare, Medicaid, federally sponsored research, and federal support of education. Hasty hearings and votes on narrow issues will not achieve such reform. Recent changes to Medicare have actually worsened the already disastrous status of care at the end of life. Legislators must attend to the need for thoughtful debate on these issues and must seek to arrange hearings, mark-ups, and votes so that wise and comprehensive reform is encouraged.
Second: This bill would not stop physician-assisted suicide in Oregon. The bill only considers drugs regulated by the Controlled Substances Act. "Controlled substances" are designated as such because they are drugs of abuse and not just because they can be lethal. There are many other ways to commit suicide. It is illuminating to note that Jack Kevorkian often used carbon monoxide to assist in suicide. Carbon monoxide is not even a drug, much less a controlled substance.
Third: Improving education and quality of care are welcome. Some provisions in this bill represent a modest but important contribution to improving pain and symptom management. More comprehensive provisions to expand the work of the Agency for Health Care Policy and Research and the Health Care Financing Administration in improving care for the end of life are already present in other bills before the Congress this session.
Fourth: This proposal could limit the willingness of physicians generally to be involved in appropriate and adequate end of life care. The specifics of implementation are uncertain.
In Oregon, the DEA will have to determine whether a physician’s intent was to relieve suffering or to assist in suicide. Having a law enforcement officer second-guessing the intent behind the use of controlled substances near death seems certain to worry many practitioners. It remains unclear whether the law enforcement training programs authorized under this bill or the implementation of the proposed Act could mitigate this concern.
Implementation of this measure would occur at a time when the tide of change clearly favors the improved use of controlled substances for relief of symptoms. Since 1980, the United States has come to use nearly ten times as much opioid drugs per capita, and there is not yet any evidence of a pattern of overuse. Hundreds of physicians are undergoing training to teach better methods of end of life care. Indeed, more health care provider organizations are setting standards and pursuing quality improvement measures in this arena. Unfortu-nately, these gains are fragile and unsettled. Fears of being scandalized with the "scent" of narcotic drug abuse would certainly arise if DEA investigators inquire into practices of opioid drug prescribing near the end of life.
In sum, this bill will not stop physician-assisted suicide in Oregon or elsewhere. Some provisions might yield benefits, but having the DEA investigators determine physicians’ intent in prescribing a drug may scare physicians away from appropriate use of opioid medications. Thus, this bill should become part of a broader effort to secure reliably good care for the end of life. ABCD hopes that Americans can take this opportunity to debate serious fundamental reforms that would create an environment in which good care at the end of life is possible for all people with serious and complex illness.
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