Update 019: Volume 13, Number 4 (October-December 1999)

Debate over federal pain relief bill intensifies

Two years to the day after Oregon’s permissive assisted suicide law was implemented, the U.S. House of Representatives passed a measure that would prohibit the prescribing of federally controlled drugs, such as barbiturates, for the purpose of causing death or assisting another in causing death. The final vote, taken on October 27, 1999, was 271 to 156. Bipartisan support for the Pain Relief Promotion Act (PRPA) was clearly evident, with 200 Republicans and 71 Democrats voting for its passage.

The PRPA would amend the federal Controlled Substances Act of 1970 (CSA) to establish, for the first time, that aggressive pain management is a “legitimate medical purpose” for the use of drugs regulated under the CSA. In addition, the PRPA would allocate $5 million for pain control research grants and the creation of needed pain management education programs for doctors and other health care providers. But it is the PRPA’s prohibition — that to prescribe federally controlled drugs to intentionally end patients’ lives is not a legitimate medical use of those drugs and, therefore, a violation of the CSA — which has been the center of a debate that has only escalated since the House passed the measure.

PRPA opponents amplify objections

Faced with the likelihood that the Senate will also pass the PRPA, opponents of the bill have taken every opportunity to turn the tide in their favor.

In an op-ed article that was published in various newspapers across the U.S., Oregon Governor John Kitzhaber, a former physician, presented arguments calculated to resonate throughout the country. He wrote that those in Congress who are against assisted suicide “have proven willing to disregard the rights of states, the wisdom of voters, and the sanctity of the doctor-patient relationship….” “For a conservative Congress that prides itself on limited government, on freedom from government intervention, and on privacy and individual liberty, this is a tremendously hypocritical act,” he argued. [Washington Post, 11/2/99:A21]

Other Oregon politicians voiced similar objections. “Oregonians have spoken clearly on [assisted suicide] — twice.” said Rep. David Wu (D-Ore). “We in Oregon have decided that, while it is a painful decision, the way a terminally-ill patient chooses to exit this world is a private decision, to be made by the patient, their family, and their doctor — not by politicians or bureaucrats,” he added. [NurseWeek, 11/8/99] Two other Democratic members of the Oregon congressional delegation, Sen. Ron Wyden and Rep. Darlene Hooley, concurred in an opinion piece they co-authored. “It seems unfathomable that Congress is now contemplating inserting the intrusive nose of the federal government at such a difficult time in the doctor-patient relationship,” they wrote. [The Oregonian, 10/21/99]

But Oregon’s largest newspaper, The Oregonian, took a different stand. “Clearly, Congress has every right to update or clarify U.S. law on the use of federally controlled substances for assisted suicide,” the paper argued. “If Congress can concern itself with drug addiction, surely it can — and should — concern itself with the quality of health care across the country. It can — and should — concern itself with the effects of assisted suicide on that health care. And it can — and should — approve the Pain Relief Promotion Act of 1999.” [Editorial, The Oregonian, 10/19/99]

OMA fails to get AMA to reverse stand

Rallying around the cry that the PRPA would unduly invite federal investigations of doctors, causing a “chilling effect” on doctors’ willingness to adequately treat pain, the Oregon Medical Association (OMA) passed a resolution urging the American Medical Association (AMA) to reconsider its support of the PRPA. The AMA’s backing of the measure, along with the support of the National Hospice Organization, was a key factor in the PRPA’s passage in the House — and would likewise be a significant factor in the Senate.

But, despite pleas to the contrary, the AMA’s House of Delegates, at its December meeting in San Diego, CA, voted to continue the association’s support of the measure. AMA delegate Dr. Rex Green, a Los Angeles cancer specialist, said fears concerning federal intrusion into physicians’ treatment of pain have been greatly exaggerated by assisted-suicide activists. “This [the PRPA] is a substantial protection for physicians,” Green explained. “This is a good law.” [AP, 12/8/99]

The AMA also voted “to seek the deletion of several provisions in the bill, which attempt to establish federal protocols for pain management and palliative care.” But the group rejected a resolution calling for the AMA to withdraw its support of the PRPA if those changes are not made. [AMA Press Release, 12/8/99]

The battle wages on

Meanwhile, defenders of Oregon’s assisted suicide law continue to attack the PRPA. Dr. Marcia Angell, editor of the New England Journal of Medicine, has charged that Congressional supporters of the PRPA “would restrict the liberty of dying patients and the rights of states to regulate the practice of medicine.” [Editorial, NEJM, 12/16/99:1923-1924] Hemlock Society’s executive director, Faye Girsh, called the PRPA’s passage by the House “an outrage to the dying.” [Hemlock Press Release, 10/27/99] And U.S. Attorney General Janet Reno — who in 1998 ruled that, unlike the rest of the 49 states, Oregon was exempt from federal action under the CSA with regard to assisted suicide — told reporters after the House passed the PRPA, “We were disappointed in the vote, and we will be working in the Senate to see what can be done.” [AP, 10/28/99]

Oregon officials have indicated that, if the PRPA is passed by the Senate, the state will take its case to court. “When and if we see a final bill come out of Congress,” a spokesman for the attorney general’s office warned, “we will examine our legal remedies.” [AP, 10/29/99] Oregon Deputy Attorney General David Schuman framed it this way: “The question isn’t whether or not this is something that is appropriate for Congress to do or something that would be a good policy decision on the part of Congress. The question is whether or not Congress has the constitutional authority to do it.” [Transcript, PBS News Hour, 10/27/99]

Euthanasia activists show ghoulish side

It was a conference cloaked in secrecy. Only a select group of 28 “experts” with “hands on” euthanasia and assisted suicide experience were invited. Even the meeting’s location was kept secret, with just a few hand-picked reporters from the U.S. and Australia allowed to attend only part of the conference. According to Derek Humphry, head of the Euthanasia Research & Guidance Organization (ERGO) which sponsored the 2-day November conference in Seattle, Washington, “We didn’t want observers, moralists, philosophers” or protesters. [Seattle Times, 11/15/99]

The participants for this first-ever “Self-Deliverance New Technology Conference” (“The NuTech Group” for short) included Dr. Philip Nitschke from Australia, Dr. Pieter Admiraal from the Netherlands, Dr. Kurt Schobert from Germany, euthanasia activists John Hofsess and Russell Ogden from Canada, Faye Girsh from the Hemlock Society USA, and other lesser known activists.

They had all come together for an induced death “show and tell” session, to see demonstrations of various contraptions and discuss strategies which might possibly make a easy and quick death a reality without the use of federally controlled drugs. As one Australian reporter aptly described it, “For many of the participants…it is like finally emerging from the underground, a place where they can demonstrate their crude, hardware-store suicide devices to others who will not recoil — the wacko fringe of the euthanasia movement moving into the mainstream.” [Gay Alcorn, Sydney Morning Herald, 12/18/99]

One of the new inventions, described by Humphry as “the most extraordinary development,” is the “DeBreather.” The person slated to die wears a tightly secured rubber mask attached to a network of tubes and canisters filled with chemicals, all designed to remove oxygen from the air the person breathes According to Humphry, the DeBreather “has been used in at least six cases of assisted suicide so far in the USA,” but still needs work and needs “to be carefully manufactured.”

Other “promising” killing techniques take the old plastic-bag-secured-over-the-head method— which Humphry touted in his suicide manual, Final Exit, but now admits takes a long 30 minutes or more to end life—and add inert gases like helium, nitrogen, or neon delivered through a tube inserted loosely into the plastic bag or directly into the mouth or nostrils. These methods, participants were told, can cut the dying time down to around 5 minutes. [D. Humphry, “Self-Deliverance—New Technology,” posted on ERGO’s web site, 12/3/99]

But the man lying on the floor with a plastic bag over his head, demonstrating the inert gas method, admitted that people “can have muscle spasms and even back-arching like someone would have in a seizure.” “If I was doing it to myself,” he added, “[I’d] not take anything for it and, like they say in the rodeo, let her buck.” Reportedly, Dr. Pieter Admiraal, the retired anesthesiologist recognized as the father of euthanasia in the Netherlands, watched in utter disbelief. According to one account, a flabbergasted Admiraal said, “They are going back to the middle ages!” “It’s not even in the hands of doctors, but laymen…[I]t is really astonishing how it could go on.” [Sydney Morning Herald, 12/18/99]

But Dr. Philip Nitschke, known as the “Kevorkian Down Under,” was no more professional in his approach to killing than the “laymen” reporting on deoxygenated air or lethal gases. Nitschke, a general practitioner who runs 4 euthanasia clinics in Australia where people can find out how to end it all, wants to develop a “suicide pill,” which he calls the “Holy Grail.” The pill, he says, must be easily concocted from common ingredients the government can’t ban. He’s most interested in drugs which were rejected during the 1930s because they were too dangerous, but, nevertheless, people could brew up at home. [Seattle Times, 11/15/99]

In a commentary published in the New York Post, IAETF lawyer Wesley J. Smith observed, “But as the Self-Deliverance Technology Conference clearly illustrates, assisted suicide isn’t at all about health care or the proper treatment of illness or disability. Beneath the propaganda of compassion and the euphemisms for killing such as ‘aid-in-dying,’ assisted suicide is purely and simply about making people dead.” [NY Post, 11/26/99]

The conference was also a clear admission that things are not going well for the right-to-die movement in America. With Congress threatening to ban the use of barbiturates for assisted suicide (see p. 1), a major segment of the movement appears ready and willing to take “death with dignity” to new lows.

The “inevitable” legalization of euthanasia, which Derek Humphry and others have been predicting for years, has thus far remained only a prediction. “If you look at the second edition of Final Exit,” Humphry told a reporter, “it says in there that you should now be able to get these drugs [for assisted suicide] from some doctors. It says the time is near when euthanasia will be legalized in many places. Well, I was wrong.” [Sidney Morning Herald, 12/18/99]

Pain Relief Promotion Act allows caring, not killing
by Rita L. Marker

In late October, the Pain Relief Promotion Act (PRPA) passed in the U.S. House of Representatives. Its passage was greeted by a collective howl of outrage from assisted suicide activists. In an effort to head off approval in the Senate, they immediately launched a barrage of misinformation about the bill.

They claimed the PRPA tramples on states’ rights and would overturn Oregon’s assisted-suicide law. They said it creates new, draconian, federal penalties and gives federal agents additional authority to intimidate doctors. They declared it the work of partisan conservative hacks in smoke-filled rooms.

Now, these claims would certainly be cause for alarm, if they were true. But they’re not. As John Adams said, “Facts are stubborn things.” And the facts don’t support the rhetoric of those who oppose the PRPA.

The PRPA is designed to promote effective pain control and to retain a uniform national standard over federally controlled substances. It’s the first section — aptly titled “Reinforcing Existing Standard for Legitimate Use of Controlled Substances” and consisting of a mere four sentences — that has caused the furor. It simply states that “nothing in this section authorizes intentionally dispensing, distributing, or administering a controlled substance for the purpose of causing death or assisting another person in causing death.”

The federal government has had the responsibility of overseeing a narrow class of drugs ever since the Controlled Substances Act was first passed in 1970. The PRPA reinforces already existing authority over this class of drugs, making it clear that intentionally causing death does not promote public health and safety and, thus, is not a legitimate use of federally controlled substances.

As a practical matter, it’s important to know that not every intentionally lethal prescription is a prescription for a controlled substance. One needs to look no further than the Physician’s Desk Reference to see that almost every drug has a potentially deadly dose.

The PRPA would not overturn Oregon’s law permitting assisted suicide. That law would remain in effect. Oregon physicians could still prescribe a lethal dose of drugs that are not federally controlled substances. And if other states decide to follow Oregon’s lead of transforming the crime of assisted suicide into an inexpensive “medical treatment,” they could do so.

The PRPA does not infringe on states’ rights. States issue licenses to practice medicine. The federal government issues licenses to prescribe controlled substances. The Supreme Court has said there’s no federal right to assisted suicide. And Congress passed, and the president signed, a law saying federal funds can’t be used to pay for assisted suicide. (Oregon violated that law and had to repay federal money that had been used to pay for lethal doses that killed poor patients.) But assisted-suicide activists want to be able to use federal licenses for assisted suicide.

Under the PRPA, states would still make the decisions about what state licenses can be used for. And the federal government would continue to issue federal licenses to prescribe controlled substances, consistent with public health and safety. There are no penalties included in the PRPA, nor does the act give any new or expanded authority to the Drug Enforcement Agency.

Support for the PRPA is bipartisan. Seventy-one Democrats voted for it when it passed by a vote of 271-156 in the House. The Senate version, which will be considered early next year, includes such notable Democratic sponsors as Sens. Joseph Lieberman, Evan Bayh and Christopher Dodd.

In addition to broad bipartisan support, which is no small feat in a gridlocked Congress, the PRPA is supported by scores of professional organizations dedicated to patient care. These include the National Hospice Organization, the American Academy of Pain Management, the American Society of Anesthesiologists and the American Medical Association. That’s because the PRPA is the most sweeping proposal ever offered to improve pain control and to protect doctors who, until now, have feared that providing adequate pain control could subject them to time-consuming and costly investigations about their prescribing practices.

For the first time, the Controlled Substances Act would specifically state that prescribing controlled substances to alleviate pain is a legitimate medical practice, even if this may increase the risk of death. In an Oct. 19, 1999 letter, the U.S. Department of Justice noted that the PRPA “would eliminate any ambiguity about the legality of using controlled substances to alleviate the pain and suffering of the terminally ill by reducing any perceived threat of administrative and criminal sanctions in this context.”

There’s more. The PRPA also provides training funds so health providers can keep up-to-date on the latest and best ways to alleviate pain and other symptoms associated with terminal and chronic illness.

The PRPA keeps the federal government out of the assisted-suicide business and puts it squarely on the side of caring for patients, not killing them.

Rita L. Marker is an attorney and the executive director of the IAETF. Her article originally appeared in the Detroit News, 12/30/99, and is reprinted here with permission.

Suicide unlimited in Oregon
The result of legalizing physician-assisted suicide

by Wesley J. Smith

Oregon’s assisted suicide law continues to demonstrate that permitting doctors to help kill patients is bad medicine and even worse public policy.

The most recent assisted suicide in Oregon is a case in point. On October 17, 1999, the Oregonian published an account of one patient who committed suicide with the assistance of medical professionals. The patient’s family had provided the newspaper with the details of the assisted killing, unintentionally showing how Oregon’s law endangers those who are the least capable of defending themselves.

Kate Cheney, age 85, was diagnosed with terminal cancer and wanted assisted suicide, but there was a problem. She may have had dementia, which raised questions of mental competence. So, rather than prescribe lethal drugs, her doctor referred her to a psychiatrist as required by law.

Cheney was accompanied to the consultation by her daughter, Erika Goldstein. The psychiatrist found that Kate had a loss of short-term memory. Even more worrisome, it appeared that her daughter had more of a vested interest in Cheney’s assisted suicide than did Cheney herself.

The psychiatrist wrote in his report that while the assisted suicide seemed consistent with Kate’s values, “she does not seem to be explicitly pushing for this.” He also determined that Kate did not have the “very high capacity required to weigh options about assisted suicide.” Accordingly, he nixed the assisted suicide.

Advocates of legalization might, at this point, smile happily and point out that such refusals are part of the way the law operates. But that isn’t the end of Kate Cheney’s story. According to the Oregonian, Cheney seemed to accept the psychiatrist’s verdict, but her daughter did not. Goldstein viewed the guidelines protecting her mother’s life as obstacles, a “roadblock” to Cheney’s right to die. So, she shopped for another doctor.

Goldstein’s demand for a second opinion was acceded to by Kaiser Permanente, Cheney’s HMO. This time a clinical psychologist rather than a MD-psychiatrist examined her. Like the first doctor, the psychologist found Cheney had memory problems. For example, she could not recall when she had been diagnosed with terminal cancer. The psychologist also worried about familial pressure, writing that Kate’s decision to die “may be influenced by her family’s wishes.” Still, despite these reservations, the psychologist determined that Cheney was competent to kill herself and approved the writing of the lethal prescription.

The final decision about the assisted suicide was left to an HMO ethicist/administrator who works for Kaiser named Dr. Robert Richardson. Dr. Richardson interviewed Cheney, who told him she wanted the pills not because she was in irremediable pain but because she feared not being able to attend to her personal hygiene. After the interview, satisfied that Kate was competent, Richardson gave the okay for the assisted killing.

Cheney did not take the pills right away. At one point, she asked to die when her daughter had to help her shower after an accident with her colostomy bag, but she quickly changed her mind. Then, Cheney went into a nursing home for a week so that her family could have some respite from care giving. The time in the nursing home seemed to have pushed Cheney into wanting immediate death. As soon as she returned home, she declared her desire to take the pills. After grandchildren were called to say their good-byes, Cheney took the poison. She died with her daughter at her side, telling her what a courageous woman she was.

This sad story is illustrates many profound and unsettling truths about assisted suicide:

Protective Guidelines Don’t Protect

Once the view of killing is shifted from automatically bad to possibly good, it becomes virtually impossible to restrict physician-assisted suicide to the very narrow range of patients for whom proponents claim it is reserved. The “protective guidelines” allegedly designed to guard the lives of vulnerable people soon become scorned as obstacles to be circumvented. And so, eligibility for physician-assisted suicide steadily expands to permit the killing of increasing categories of ill and disabled patients. Thus, an act that is supposed to be “rare” is likely to become more common. And what was seen as a last resort, something that might be considered if palliative treatment failed, becomes an alternative to treatment.

This has certainly happened in the Netherlands, where euthanasia has been permitted since 1973. The Dutch law, in fact, contains much stronger guidelines than Oregon’s, yet these protections have long ceased to be of any practical use and are routinely ignored with impunity. Thus, in the Netherlands, not only are terminally ill patients who ask for euthanasia killed by doctors, but so are chronically ill patients, and depressed patients who have no disease. Babies born with disabilities are also killed at the request of parents who allege their children are incapable of a “livable life.”

According to repeated reports on Dutch euthanasia, at least 1,000 patients are killed each year who did not ask to die. At the same time, 59 percent of the doctors who kill patients fail to report the deaths as required by the guidelines. One recent study of the Dutch experience, puts the matter grimly, saying physician assisted suicide is “beyond effective control.”

The same pattern is already developing in Oregon, where assisted suicide has only been permitted legally for two years. Rather than being strictly reserved for the rare case of irremediable pain, it turns out that none of the patients reported to have undergone assisted suicide were in untreatable agony. Most, like Kate Cheney, were worried about being a burden and requiring assistance with the tasks of daily living. That is a serious matter to be sure, but one which experts on treating dying people are adept at relieving.

Doctor Shopping Becomes the Key to Obtaining Death

A major selling point of assisted suicide advocacy is that close, personal relationships between doctors and patients will prevent “wrongly-decided” assisted suicides. But Oregon proves the utter emptiness of this promise. Kate Cheney and her family were not deterred in the least by a psychiatrist’s refusal to approve her self-poisoning. They simply went to another doctor.

Cheney’s family wasn’t so much looking for a medical opinion as an opinion that confirmed what they had already decided. This is reminiscent of the Woody Allen line from the movie, Manhattan. When Allen¹s character bemoans his marriage breaking up, his friend reminds him that his psychiatrist warned him that his soon-to-be ex-wife would be big trouble. Allen smiles ruefully and says, “Yea, but she was so pretty, I got another psychiatrist.”

Cheney’s case is not the only example from Oregon in which doctor shopping has resulted in hastened death. As reported in newspapers and bioethics journals, the first woman known to have legally committed assisted suicide in Oregon went to her own doctor when her breast cancer prevented her from doing aerobics and gardening. When he refused to help kill her, she consulted a second doctor. This physician also refused to help kill her, diagnosing her as depressed. So, she went to an assisted suicide advocacy group. After speaking on the phone with her, the group’s medical director referred her to a “death doctor” who was known to the group for being willing to issue lethal prescriptions. She died a mere two and one-half weeks later from the poison pills.

According to the New England Journal of Medicine, at least five other people who died by assisted suicide in Oregon in 1998 went to multiple physicians before finding one willing to help kill them. The length of time between meeting with the prescribing doctor and death in at least a few cases was 15 days–the exact waiting period required by law. Legalizing assisted suicide thus distorts medical care for patients near the end of their lives.

Primary care physicians who would prefer treating a patient who wants to be killed are jettisoned in favor of doctors with an ideological predisposition toward assisted suicide. Moreover, physician-assisted suicide means doctors who refuse to “assist” are subject to emotional blackmail. Patients can tell their physicians: Either you give me the pills or I will go to a doctor who will.

Death doctors are a malevolent twist on the draft doctors of the Vietnam War era who kept young men from being inducted by finding physical anomalies to obtain medical deferment for their “patients.” But no one pretended that draft doctors were practicing medicine. They were engaged in politics, pure and simple. The same phenomenon is now happening in Oregon, only instead of trying to save lives, death doctors ideologically support the taking of life. This means that even the most secure and long-lasting doctor-patient relationships provide zero protection against assisted suicide.

HMOs Are a Lethal Part of the Mix.

One of the awful truths about assisted suicide is that it will be performed in the context of managed care where profits are made from cutting costs. In Kate Cheney’s case, the final authority was a Kaiser HMO medical ethicist. This raises the appearance, if not the actuality, of a terrible conflict of interest. The poison that killed Cheney cost Kaiser approximately $40. It could have cost the HMO $40,000 to care for her properly until her natural death. The potential for economically-driven death decisions is too obvious to be denied and is likely to become more pronounced as people become desensitized to doctors’ acting as killers. The same can be said about government-financed health care. Oregon Medicaid, which rations health care to the poor, pays for assisted suicide.

Oregon continues to illustrate the fallacy and danger of redefining killing as a medical act. Yet, despite the warning signs, advocates continue to press legalization throughout the nation. Several states, including California, have legislation pending, while Maine voters will likely face a legalization initiative in the November 2000 election. The only question is whether we will respond to terminal illness with better medical care or ignore the horrors of the Netherlands and Oregon and step intentionally off of the ethical cliff.

Wesley J. Smith is an attorney for the IAETF. He is the author of Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder (Times Books, 1997) and the forthcoming book, Culture of Death: The Destruction of Medical Ethics in America. His article is reprinted, with permission, from The Weekly Standard, 11/8//99. (For subscription information, call 1-800-283-2014 or see www.weeklystandard.com.)

Woman comes out of “vegetative state” after 16 years

ABC News reported it as a possible “Christmas miracle” in New Mexico. Patti White Bull, 42, had been in a vegetative state for 16 years, totally unresponsive and tube fed because she could not eat or swallow. She had been in this condition since the day she lost consciousness due to a lack of oxygen to her brain while giving birth to her fourth child. Then suddenly on Christmas Eve, as a nurse’s aide was fixing her bed covers, White Bull began to talk, telling the aide, “Don’t do that.” The next day, she wrote a letter to her mother, began dressing herself, and started walking with support. Her hands, which had been tightly clenched for 16 years, were now open and relaxed.

Since her awakening, White Bull has been spending most of her time watching and listening to her children, now 25, 19, 17, and 16. She has taken a trip to the local shopping mall (her first request), and, because her ability to swallow is improving, has been able to eat chicken, mashed potatoes, gravy, and even a small piece of pizza.

Her doctor and others are amazed by her recovery. But neurologist Ronald Cranford, who has testified in numerous cases in favor of starving and dehydrating brain-damaged patients, rejected the idea that White Bull suddenly came to. According to Cranford, she probably had been subtly responsive all along, but no one noticed. “Maybe on Christmas Day,” he opined, “people noticed more than they ever had before, and that made it seem like a dramatic recovery.” [ABC News, 12/29/99; AP, 1/5/00]

Research in Review

Dying patients used for practice

A recent study published in the New England Journal of Medicine has called for the end of teaching methods which allow doctors in training to practice unnecessary invasive procedures on dying patients without their consent. Generally speaking, the families of such patients are never told about the practice procedures or asked to give informed consent.

The study centered on the procedure of inserting a catheter into the femoral vein in the groin area while the patient is undergoing cardiopulmonary resuscitation (CPR). It is a skill which doctors need to learn to perform swiftly in emergencies.

Researchers surveyed 234 interns and residents (house officers) representing three teaching programs at five Connecticut hospitals. The survey was anonymous and conducted from September through November 1998. One-third (34%) of the house officers indicated that “it is sometimes appropriate to insert a femoral-vein catheter for practice during CPR,” 26% had observed another doctor perform the procedure for practice, and 16% had personally tried the procedure.

According to researchers, some medical training programs actually encourage the use of non-consenting, dying patients as practice subjects for this procedure even though it would hold no benefit for the patient and could even harm the patient. The justification most commonly offered is the belief that these practice sessions improve doctors’ clinical skills, benefiting future patients.

But the researchers disagreed. This justification, they concluded, puts the health interests of future patients ahead of the rights of patients close to death. “Inserting a femoral-vein catheter for practice in a person undergoing CPR when the procedure is not medically indicated or when informed consent has not been given is inconsistent with current standards of medical ethics that are based on principles of beneficence, nonmaleficence, and respect for patients’ autonomy.” “Training programs should consider how aspects of clinical education may unintentionally reinforce attitudes that can reduce patients to mere objects of use in education.” [L.C. Kaldjian et al., “Insertion of Femoral-Vein Catheters for Practice by Medical House Officers during Cardiopulmonary Resuscitation,” NEJM, 12//30/99, 2088-2091].

Medical errors cause death and injury

Anywhere between 44,000 to 98,000 patients per year die unnecessarily due to medical errors in U.S. hospitals, according to an alarming report issued by the National Academies of Sciences’ Institute of Medicine (IOM). Medical mistakes account for more deaths annually than highway accidents, homicide, breast cancer, or AIDS. Combined with nonfatal errors that result in serious injuries, medical mistakes cost the U.S. as much as $29 billion each year.

“These stunningly high rates of medical errors — resulting in deaths, permanent disability, and unnecessary suffering — are simply unacceptable in a medical system that promises first to ‘do no harm,’” said William Richardson, head of the committee that issued the report. “Our recommendations are intended to encourage the health care system to take the actions necessary to improve safety,” he explained. “We must have a health care system that makes it easy to do things right and hard to do them wrong.”

The committee found that the majority of mistakes were not caused by individual recklessness, but rather by “basic flaws in the way the health system is organized.” For example, the common practice of stocking certain full-strength drugs in hospital patient-care units has resulted in fatal errors. Some of those drugs are toxic unless the hospital staff person dilutes them before giving them to the patient. The often hectic environment of patient-care units can provide an atmosphere ripe for errors in drug administration.

The 223-page report, entitled To Err Is Human: Building a Safer Health System, proposes strategies for reducing errors by at lease 50% over the next 5 years. Among those proposals are the creation of a national center for patient safety and the establishment of mandatory and voluntary error reporting systems. [NAS IOM Press Release, 11/29/99]

Racial inequities in pain treatment

A study reported in the Annals of Emergency Medicine found that black patients have a 66% higher risk of receiving no pain medication compared to white patients, despite the fact that both groups had similar injuries and complaints of pain. This study, the authors wrote, adds to the accumulating “evidence that minority patients are not receiving timely and appropriate medical care when compared with nonminority groups.”

Lead researcher Dr. Knox Todd and colleagues at Emory University reviewed the medical records of 201 patients who had received treatment for a broken arm or leg at one emergency department in Atlanta, Georgia. The data revealed that 74% of white patients were given pain medication as opposed to 57% of black patients. “Inadequate prescribing of pain medication is common among emergency department patients,” Todd explained. “This is the second study we have conducted showing that minorities are at higher risk than whites for undertreatment of pain.” In the earlier study, conducted in Los Angeles, researchers found that Hispanic patients received pain medication less frequently than white patients. [Reuters Health, 12/28/99]

Commenting on these findings, Dr. Eric Chevlen, an expert in pain control and an IAETF medical consultant, said, “Since uncontrolled pain is a common factor leading to a request for physician-assisted suicide, the inadequate treatment of pain for racial minorities makes them a particular target of the euthanasiast.” [E. Chevlen, personal communication, 12/29/99]

Lack of coverage linked to poor health

Patients in the U.S. who do not have health insurance coverage become sicker and are more likely to die prematurely than those with insurance. Those were the findings of a study report issued by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) “Uninsured Americans may be up to three times more likely than insured individuals to experience adverse health outcomes,” said ACP-ASIM president Whitney Addington, M.D. “They are up to four times as likely as insured patients to require both avoidable hospitalizations and emergency hospital care,” he added. [ACP-ASIM Press Release, 11/30/99]

According to the report, Americans who lack insurance have a higher mortality, particularly a higher in-hospital mortality. Because of their significantly reduced access to preventative medical care, the uninsured are more likely to develop serious complications from illnesses which can normally be avoided, resulting in higher medical costs and a loss of productivity.

The report cites the U.S. Census Bureau’s estimate that 44.3 million people (16.3% of the population) had no health insurance in 1998. That was an increase of approximately 1 million people over the 1997 figures. Individuals most likely to be uninsured include those in the 18-24 age group, people with lower levels of education, minority groups, part-time workers, and those born in other countries. Among minority groups, Hispanics are the most uninsured (35%), followed by African-Americans (22%), Asians (21%), and Non-Hispanic Whites (12%). [ACP-ASIM Report, “No Health Insurance? It’s Enough to Make You Sick—Scientific Research Linking the Lack of Health Coverage to Poor Health,” 11/30/99]

Many doctors favor deceiving insurers to get coverage for patients

According to a study published in the Archives of Internal Medicine, many doctors “sanction the use of deception” to obtain treatment approval for their patients from health maintenance organizations (HMOs) and other health care insurers.

The study used a mailed survey to evaluate “physician willingness to use deception in 6 vignettes of varying clinical severity.” Of the 169 internists surveyed nationwide, 58% indicated that they would favor deception to get authorization for coronary bypass surgery, 56% for arterial revascularization, 48% for intravenous pain medication and nutrition, 35% for mammography, and 32% for a psychiatric referral. Only 2.5% indicated a willingness to deceive insurers for cosmetic rhinoplasty (nose job). Over a quarter of the respondents (27%) did not favor deception for any of the treatments, while 14% supported the use of deceit in all the cases except cosmetic rhinoplasty. [V.G. Freeman et al., “Lying for Patients: Physician Deception of Third-Party Payers,” Archives of Internal Medicine, 10/25/99, 2263-2270]

Dr. Daniel P. Sulmasy from New York Medical College in Valhalla, a medical ethicist and co-author of the study, presented the survey’s findings at the October meeting of the American Medical Association at UCLA. “We need to remove the doctor from the position of being both the patient’s advocate and the cost controller,” he told the group. “Those two roles are almost always in direct conflict.”

Sulmasy said some doctors feel that using deception is not necessary when physicians act as patients’ advocates in attempting to get an insurer to cover needed treatment. But, according to Sulmasy, doctors often suffer from “appeal fatigue” as a result of numerous battles with insurers. “It’s easier to give up or to fudge the billing sheet,” he explained. “What we need is a better system of cost containment.” [Los Angeles Times, 10/25/99]

News Notes

Dr. Georges Reding, the former apprentice of Jack Kevorkian, will be facing mounting legal problems in New Mexico — that is, if he’s captured. Reding became a fugitive on 9/3/99 after he failed to show up for his arraignment on a 4-count indictment charging him with first-degree murder, drug trafficking, evidence tampering, and practicing medicine in New Mexico without at license. The charges stem from the 8/30/98 death of multiple sclerosis patient Donna Brennan, 54, who, according to the autopsy, was given a lethal injection of pentobarbitol. Detectives were able to place Reding, a Michigan psychiatrist, at Brennan’s New Mexico home just prior to her death. (See Update, 7-9/99.)

Now, in addition to the criminal charges, a wrongful death civil suit has been filed against Reding by Brennan’s family. On 11/5/99, a district judge found Reding liable for Brennan’s death, and, on 12/16/99, the judge issued a default judgement in favor of the family when Reding failed to respond to the suit. A hearing will be set to determine compensatory and punitive damages suffered by the family for the loss of Brennan’s life as well as for her hospital and burial expenses. New Mexico authorities are on Reding’s trail, saying that he has been on the run in Europe. [AP, 12/16/99 & 11/13/99]

So far, lawyers for convicted felon Jack Kevorkian have been unsuccessful in their attempts to get the death doc released from prison. Most recently, they filed a motion to have him freed on bail pending his conviction appeal. Currently, however, Kevorkian remains in a remote

Michigan prison serving 10-25 years for the euthanasia death of Thomas Youk, an ALS patient whose death was aired on CBS’ 60 Minutes. Kevorkian, 71, will not be eligible for parole until May 2007. [Detroit News, 12/30/99]

According to Faye Girsh, president of the Hemlock Society USA, the Hemlock Foundation “will be providing matching funds for contributions” given for Kevorkian’s legal defense. Also, the foundation has made donations to the defense coffers of Dr. Georges Reding and Dr. Lance Wilson, the Illinois doctor who admitted giving a lethal injection to 69-year-old patient Henry Taylor. (See Update, 7-9/99.) Charges against Wilson were dropped because prosecutors said they did not have enough evidence to prove that he intended to kill Taylor. [F. Girsh, Right-to-die e-mail server list, 1/5/00]

Salt Lake City, Utah, psychiatrist Robert Allan Weitzel has been charged with five counts of first-degree murder. According to police, Weitzel, 43, systematically killed five geriatric patients over a span of 16 days with morphine overdoses. Each count carries a possible life sentence.

Weitzel was the director of the Geriatric-Psychiatry Unit at Davis Hospital and Medical Center, a position he held for only a month before the patients suddenly started dying. The deaths occurred between December 1995 and January 1996. None of the five victims, ages 72 to 93, had conditions which would have caused a natural death or warranted the administration of morphine. Yet, at Weitzel’s arraignment, his attorney, Peter Stirba, argued, “It is unfortunate that the state is trying to criminalize the routine providing of comfort care during the dying process. Obviously, [Weitzel] did not over-medicate.”

Weitzel also faces other legal problems. Last September he was charged in federal court with 22 counts of fraudulently acquiring prescription painkillers for himself. The federal Drug Enforcement Agency (DEA) has since barred Weitzel from prescribing drugs. [Salt Lake Tribune, 11/8/99; AP, 9/29/99]

In Switzerland, the euthanasia advocacy group Exit helps people commit suicide. Its president, Elke Baezner, claims that all the people who receive death assistance from Exit are terminally ill or incurably ill. Last year alone, the group’s “Companions in Death” program helped 120 people die from barbiturate overdoses and provided hundreds more with how-to manuals. Switzerland does not prohibit non-doctors from aiding a suicide. It does prohibit people with a “selfish motive” from doing so, but there is no prohibition for anyone else. While Exit is allowed to get the fatal drugs from willing doctors and prepare them for those who are terminally or incurably ill, members may not administer the drugs.

But a recent study at Basel University has caused people to question whether Exit does limit its services to the terminally or incurably ill. Researchers cited the case of an elderly man whose death Exit facilitated. The group had reported that the man was terminally ill with lung cancer, but a subsequent autopsy found that the man only had bronchitis. In another instance, Exit agreed to help a 30-year-old clinically depressed woman. Authorities interceded and stopped Exit from giving her the overdose. [Los Angeles Times, 10/10/99]