End-of-life care takes forefront

Physician-assisted suicide was a hot issue in bioethics in the mid-1990s, when Oregon became the first state in the nation to legalize the controversial practice.

Today it doesn't command the same attention. Though opinions on the topic remain deeply divided, the debate has gradually shifted to a larger concern — the way America cares for people who are dying.

"The central issue, we all realize, is end-of-life care," said Dr. Ezekial Emanuel, chairman of the department of clinical bioethics at the National Institutes of Health. "Assisted suicide is really a sideshow."

For the vast majority of people who are terminally ill, the question is not whether they'll ask a doctor to help them end their life, it's whether anyone can relieve their depression and manage their pain, Emanuel said.

Even in the Netherlands, the country where the practice is most deeply entrenched, only a tiny percentage of terminally ill patients ask physicians to help them end their lives, he noted.

In Oregon, 208 terminally ill patients committed suicide with doctors' help between 1997, when the law went into effect, and 2004. Physicians had been quietly helping patients end their lives even before the law was passed, and there's no indication that assisted suicides increased after they were legalized, said Dr. Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health & Science University.

The biggest change, Tolle and others report, is the attention Oregon has devoted to improving end-of-life care — especially pain treatment and hospice care — since the law was passed.

Other states


A ruling Tuesday by the Supreme Court offered protection for Oregon's one-of-a-kind assisted-suicide law. Some other states where assisted-suicide proposals have been discussed:

California: A bill to allow doctor-assisted suicide comes up for a vote in March in the Assembly's Judiciary Committee.

Vermont: Backers of assisted suicide tried unsuccessfully to bring a proposed law to a vote in the Legislature last year. A similar death-with-dignity bill was filed this year and awaits action.

Connecticut: A bill was introduced in the General Assembly last year dealing with assisted suicide but did not survive the legislative session.

Hawaii: In 2002, Hawaii came within three votes of becoming the second state to allow doctor-assisted suicide. Similar bills have stalled in the Legislature since then.

Maine: Voters in 2000 narrowly rejected a proposal to allow physician-assisted suicide. Similar proposals were rejected by the state Legislature four times before supporters launched an initiative drive that forced the proposal to the ballot.

Michigan: A law enacted in 1998 made physician-assisted suicide a felony. Voters later that year soundly defeated a ballot measure that would have made assisted suicide legal under certain guidelines and in effect overturn the Legislature's ban.

Washington: Voters in 1991 rejected a proposal to allow doctor-assisted suicide. The measure would have overturned an existing ban on the practice.

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"Now we can get over the distraction of this debate and get on with the real business at hand: delivering the best possible care to dying patients," said Dr. Peter Rasmussen, a Salem, Ore., oncologist who said he had assisted in suicides of "more than a dozen" patients.

Critics see a much darker side to the issue. "Assisted suicide will discriminate against the old, the ill and the disabled," said Diane Coleman, president of Not Dead Yet, a Chicago-based disability-rights group that filed an amicus brief supporting the government's effort to overturn Oregon's law. Vulnerable, expensive-to-treat patients will get medications to help them die because their lives won't be seen as worth living, she contends.

Depression, hopelessness and fear of becoming a burden are primary reasons critically ill patients consider suicide, experts confirmed. Surprisingly, pain is a less important factor.

Physicians organizations such as the American Medical Association remain adamantly opposed to the concept of physician-assisted suicide. "As a physician, I don't think helping patients end their lives is a proper thing to do," said Dr. Kenneth Stevens, an oncologist and vice president of Physicians for Compassionate Care, a group that opposes the Oregon law.

One important issue in the Oregon case, physicians said, was their ability to treat dying patients without interference from the government. The Bush administration had argued that doctors who help patients end their lives could be prosecuted under federal drug laws.

"Doctors are already afraid to prescribe narcotics appropriately. If [U.S. Attorney General Alberto] Gonzales had beaten Oregon, it would have put the fear of the FDA into every doctor trying to provide palliative and hospice care in America today," said John Lantos, associate director of the University of Chicago's MacLean Center for Clinical Medical Ethics.

On the political front, the question now becomes whether statehouses or Congress will take up the issue.

Some experts suggest other states may now follow in Oregon's footsteps; others believe that's unlikely. Connecticut, Hawaii, Maine, Michigan and Washington have rejected assisted-suicide bills; California and Vermont are scheduled to consider proposed bills this spring.

At the federal level, legal experts say the high court's relatively narrow ruling left the door open for Congress to act. Congress already has restricted the use of federal funds for assisted suicide — a ban that President Bush's predecessor, Bill Clinton, supported.

In writing the court's majority opinion, Justice Anthony Kennedy noted that "the federal government can set uniform standards for regulating health and safety."

"At this point, the recourse is congressional," said Marc Spindelman, a bioethics expert and law professor at Ohio State University. "It would be surprising if the Republican-controlled White House and Republican-controlled Congress didn't see some grist for their conservative base."

James Bopp Jr., general counsel of the National Right to Life Committee, agreed that "a logical reaction" would be legislation that explicitly prohibits the use of federally controlled substances in assisted suicide.