Boston Globe, January 19, 2006

Treating the pain by ending a life

By Dr. Mark Siegel

THE US SUPREME court ruled this week that doctors in Oregon should not be charged with a crime for overdosing patients in the name of treating pain and hastening death. This decision should be applauded and must not be circumvented by new laws.

Ten years ago I assumed the care of a woman with advanced pancreatic cancer that had spread to her spine. She was a well-known writer, and we quickly became friends. I would travel to her apartment and visit her for hours there, something I'd rarely done before and haven't done since. She had a close group of friends who visited her constantly, and an Irish nursing agency that cared for her impeccably around the clock. At first her cancer wasn't causing her pain, though it paralyzed her below the waist and bound her to her bed and wheelchair. Still, she enjoyed the visits, mine and everyone else's, until the fateful day when the cancer spread to her bones and began what was clearly an escalating pain. I dialed up the morphine to compensate, until the day came when the amount of morphine necessary clearly hastened her death. I was able to predict roughly the time she would die, and her friends said their goodbyes. I used morphine in the name of relieving suffering, not as a murder weapon. No one who knew her seemed upset by the trade-off, a tortured life for a peaceful death, and all thanked me for my care at the end.

Morphine and other narcotics suppress breathing and lower blood pressure. It is not unusual for physicians to use these drugs to relieve suffering and thereby accelerate death in terminal cases. What is unusual is for doctors to be prosecuted for overdosing their patients deliberately in the name of this cause. Oregon has been the focus of the Bush administration's attempts to criminalize the activity, but this use of medications to knowingly end a tortured life is not confined to Oregon. It has been part of a physician's end-of-life role for many years, whether it is formalized in the law or not.

Any effective physician has two fundamental roles. The first is to prolong life. The second is to ease suffering. In most situations, easing suffering is part of prolonging life, as when we guide a patient through an accident or a surgery and treat pain as part of ensuring survival. Sometimes, though, our two roles collide, and a decision must be made as to which to prioritize. This decision is made, in part, by considering long-term outcome as well as the wishes of the patient. It is never a perfect situation, but we physicians have been making this determination for eons, and we cannot be penalized or prosecuted and still be expected to function.

In the Netherlands, active euthanasia is legal, which means that a cancer patient who is still ambulatory and thinking clearly can ask a doctor for a lethal injection. I am not in favor of this policy, not because I believe that a person doesn't have a right to end his or her life when given a terminal diagnosis, but because I question the role of a physician in facilitating this outcome. Such a role should not be assumed, because it is not strictly a part of relieving suffering.

But this is not the same thing as the Oregon law, which allows a physician to participate when pain predominates, when a patient is in agony, when reducing morphine cannot bring back quality of life. When the only choice is pain or death, doctors routinely -- with their patients' advance approval -- help them choose death. The US Supreme Court is wise to acknowledge one of our fundamental roles. We are not ''Kevorkian-izing" our doomed patients when we help ease their path from this world.

Dr. Marc Siegel, associate professor of medicine at NYU School of Medicine, is author of ''False Alarm: The Truth About the Epidemic of Fear" and the forthcoming ''Bird Flu: Everything You Need to Know About the Next Pandemic."

© Copyright 2005 The New York Times Company

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