Hyde-Nickles bill poses threat to pain relief

Groups mobilize against it

Federal anti-assisted suicide legislation, described by pain management advocates as "dangerously misguided" for the chilling effect it would have on the prescribing of controlled substances for terminally ill patients’ pain, it was on a fast track in Congress this year, but it was withdrawn during the last week of the session.

Don’t breathe a sigh of relief just yet, though. Sen. Don Nickles (R-OK), a cosponsor of the bill, has promised constituents that he’ll revive the legislation again next year.

The Lethal Drug Abuse and Prevention Act, H.R. 4006/S. 2151, was introduced in Congress this summer by Rep. Henry Hyde (R-IL) and Nickles. It would create a medical review board within the federal Drug Enforcement Agency (DEA), authorized to investigate, prosecute, and revoke the DEA registrations of any physician or pharmacist who "intentionally dispensed or distributed a controlled substance with a purpose of causing or assisting in causing" a suicide.

Oregon is the only state where assisted suicide is legal, but the issue has surfaced in legislative and ballot initiatives elsewhere, including Michi gan and Hawaii. Voters in Michigan, for example, will decide whether to allow assisted suicide on the November ballot through a referendum.

The bill "was definitely on a fast track. We knew it would go to the House floor in [early fall], having passed out of the House Judiciary Committee on a vote reflecting party lines," says John Giglio, director of public policy and general counsel for the National Hospice Organization (NHO) in Arlington, VA. The NHO sent urgent fax memos to its members, urging them to "respond in force" by contacting their congressional representatives regarding the dangers of this bill.

While the bill enjoys powerful supporters in Congress, as well as the full lobbying force of the National Right-to-Life Committee of Washington, DC, it is opposed by a long list of health- and pain-related organizations. Some of these opponents, such as the NHO and the American Medical Association (AMA) in Chicago, have a long history of opposition to assisted suicide.

Other opponents include the American Academy of Hospice and Palliative Medicine in Alexandria, VA, the Hospice and Palliative Nurses Association in Pittsburgh, the Hospice Association of America in Washington, DC, and other national advocacy groups. The NHO organized a coalition of groups opposing the bill and held an informational luncheon for legislative aides in August.

The AMA, the largest of these groups, reiterated its staunch opposition to assisted suicide, while opposing this particular method of blocking its legalization. "We’d do anything to avoid the intrusion of the federal government into physicians’ offices," says AMA chairman Thomas Reardon, MD. "If the issue for Congress is physician-assisted suicide, why not just be clear with it? Why create this new oversight by the Justice Department, second-guessing physicians." But when asked if the AMA plans a concerted, all-out effort to defeat the Hyde-Nickles bill, Reardon replies, "We’ve made our feelings known. It’s an important issue for us. It does put us in an awkward situation, to oppose assisted suicide and this bill, but we think the bill is wrong."

Pain management advocates, such as June Dahl, PhD, professor of pharmacology at the University of Wisconsin in Madison, complain that members of Congress appear to have little interest in advocates’ fears about the bill’s threat to pain management. "It’s very difficult for others to appreciate the level of paranoia doctors have about state medical boards and the DEA. These fears are not based in reality, but that doesn’t make their fears any less persuasive," Dahl says. "Ironically, the drugs likely to be used for physician-assisted suicide wouldn’t be controlled under this ill-conceived legislation."

"The kinds of ways it risks delaying improvements in end-of-life pain control are likely to be much more subtle than just DEA investigations of doctors," says Joanne Lynn, MD, director of Americans for Better Care of the Dying (ABCD) and the Center to Improve Care of the Dying in Washington, DC. However, being targets of such an investigation will change physicians’ prescribing forever after — even if they are exonerated, Lynn adds. Although the issue may be settled by the time this newsletter is published, Lynn urges ethics committees to watch ABCD’s Web site for updated information (www.abcd-caring.com).

Thanks in part to the attention to end-of-life issues generated by the assisted suicide debate in Oregon, that state now has the highest per capita rate of prescribing morphine for pain management. However, asserts Ann Jackson, executive director of the Portland-based Oregon Hospice Association, "If things are so good here regarding pain management, then the rest of the country is truly in trouble. We aren’t doing anywhere close to what we should be doing in this area," she says.

"We have struggled with the issue of physicians who just plain don’t want to prescribe [opioid] pain medications for their patients. I have attended pain and symptom management task force meetings, and a number of public hearings have underscored the barriers in this area. It is the fear of the medical board and of DEA scrutiny that keeps physicians from prescribing adequately. The effects of the Hyde-Nickles bill on physicians would be devastating, even if they are inadvertent," Jackson says. (For more information on what’s happening in Oregon, see story, below.)

Medical Ethics Advisor will continue to follow the legislation in the next session of Congress.