Would You Desire Your End-of-Life Care Managed by a DEA Agent?
A Perspective commentary by Timothy E. Quill, M.D., and Diane E. Meier, M.D. in the January 5th 2006 issue of the New England Journal of Medicine describes the chilling effect on physicians' provision of comfort care of terminally ill patients because of the November 2001 U.S. Attorney General John Ashcroft directive which states that the prescription of Schedule 2 medications under the Oregon law violates the Controlled Substance Act since “assisting in a suicide is not a ‘legitimate medical purpose’” The commentary suggests that “If passed, this directive would allow the federal government to overrule established state law, empower the [Drug Enforcement Agency] DEA to investigate whether a violation had occurred, and potentially open to investigation every instance of prescribing of a controlled substance for a dying patient.” and not simply if administered under Oregon law.
The directive was taken to court by the state of Oregon and others with the argument that it should be the state’s responsibility to determine “legitimate medical purpose” and not the Controlled Substance Act. While the Ninth Circuit Court of Appeals supported the Oregon argument, the case was subsequently heard in the U.S. Supreme Court, which has as yet not announced a decision.
The authors conclude: “This type of DEA involvement in medical practice would adversely affect far more patients than those few who seek assistance with a hastened death in Oregon. If the government thus oversteps its legitimate role and expertise, allowing DEA agents, trained only to combat criminal substance abuse and diversion, to dictate to physicians what constitutes acceptable medical practice for seriously ill and dying persons, it will undermine palliative care and pain management for the much larger number of seriously ill patients in all states. Physicians may become hesitant to prescribe the best available medications to manage the pain, agitation, and shortness of breath that sometimes accompany the end stages of illness. As a result, they may, in essence, abandon patients and their families in their moment of the greatest need”
I have no doubt that the dire predictions of Quill and Meier will come true if the directive is sustained. We physicians will not risk jail time or heavy fines for performing humane patient comfort care. Better, society finally decides who sets the standards of practice, the States and their physicians or DEA agents And if the latter, perhaps the DEA agents would want to take over end-of-life patient management themselves. Any sarcastic comments to my sarcastic suggestion? ..Maurice.
posted by Maurice Bernstein, M.D. @ 9:11:00 PM
8 comments
8 Comments:
Maurice - It is tragic when physicians fail to provide adequate comfort care to their patients out of fear that they will be persecuted (yes, that word choice was intentional) by the DEA. It is similarly tragic, however, when they are persecuted by disgruntled patients with friends in high places who manage to pass laws mandating the provision of treatments without a solid medical rationale (e.g., routine BMT for breast cancer).
My reference above to a "solid medical rationale" is, I think, important. Without such a rationale, does it matter who sets the standards of practice? When it comes to intentionally facilitating the deaths of patients, just what is the medical rationale by which this could be assimilated to "treatment?"
Bob, I may have answered this elsewhere but I'll restate it here. If you assume that the responsibility of a physician is not only to attend to and treat the physical aspects of the illness of a patient but also the psychologic aspects then there may be a "solid medical rationale" for assisted suicide as practiced in the state of Oregon. If the patient finds that the physical illness and its effects are no longer treatable or bearable and there is no associated treatable major depression present, then one could argue that providing a way for the patient, at his or her own time and action, to get the wanted relief would be part of the overall treatment of the patient's whole condition. Though I can understand the rationale, I would not wish to participate because I would not be certain that physicians should be intentionally facilitating the death of a patient for whatever rationale. Now if the state would like to assign "death pharmacists" to make the drugs available to the appropriate patients, well.. that is society's decision. I know that you might think that I am "chickening out" as a physician but that is my view. ..Maurice.
Maurice - I've never objected to including psycho-social dimensions of health and disease in the domain of medical concerns. Rather, what I've objected to is the lack of concern on the part of medical professionals with the disciplinary integrity of medicine. If you leave it patients (or worse, legislators and judges) to determine what purpose(s) are served by medicine, then physicains ought to drop the pretense that they are members of a profession with internal standards of knowledge and practice -- and acknowledge that they are just another group of technicians for hire.
Bob, the medical/scientific/empiric basis for treatment should be set by physicians and not politicians or others. However, since it has been society which has set the role of physicians and has given us the direction, rights and privilidges of our profession, it will be society that resets our role and not independently by physicians. So far, society has allowed physicians to terminate life-support at the patient's request, administer drugs for therapy which potentially might cause death of the patient, touch and examine patients without legal penalty of homicide or battery. Oregon society has allowed physicians to prescribe a potentially lethal dose of medication, under restricted conditions, for the patient's use without legal penalty. As I noted before, I would appreciate if society would provide a non-physician specialty for assisting suicide, if that is what is wanted, and allow physicians to continue their roles free of the permission to intentionally causing the death of a patient. ..Maurice.
It's one thing for society to set certain boundaries to the practice of medicine; e.g., to prevent its being co-opted for anti-social (perhaps even criminal) purposes, to mandate the provision of care in various circumstances, or even to determine what resources will be available for healthcare. But it's something else entirely for society to "set the role" of medicine if that means treating healthcare as a "mere" means to certain social ends other than health itself.
That's how we get medicine redefined so that health is no longer the animating principle of medical activity. That's how we get inappropriate medicalization.
Bob, I am afraid that it really is society that sets the role of my practice of medicine. I am sure, for example, that it wasn't physicians themselves who altered the role of the physician from a fatherly (paternalistic) advisor and treater to one who must not dictate to the autonomous patient but simply educate the patient about the alternatives and simply wait and listen for the patient's own decision. It was society in the age of consumerism that did that. It is society that has repeatedly introduced the medicalization of non-medical issues directing physicians into inappropriate practices.
I don't know how physicians alone can buck the pressures of society and make changes more consistent with the many years of the classical goals and roles of physicians. Unless we just opt out, as I am doing with the issue of society inspired assisted-suicide. ..Maurice.
Maurice - Physicians can reject paternalism, with its assumption that "good" patients will follow their "doctor's "orders," without giving patients or society the power to dictate the goals of medicine. Pursuing health within a consumerist framework rather than a paternalistic framework is still the pursuit of health -- just within different parameters (what I earlier called 'boundaries').
What I have protested against is the notion that in a consumerist context whatever the tools of medicine can do to further a patient's goals is constitutive of the pursuit of that patient's health. That's utter nonsense, even if it's politically incorrect to say so.
I failed in my previous message to address Maurice's statement that "It is society that has repeatedly introduced the medicalization of non-medical issues directing physicians into inappropriate practices."
I'm afraid this is a very one-sided view of things. Physicians experience an increase in power, both in the extent of the domain where they claim "expertise," and in the range of "services" for which they can charge fees, when problems are newly medicalized.
Physicians have certainly been "pressured" by insistent patients and even "society" to use their knowledge and skills for various "non-medical" purposes. But physicians have also, on occasion, played a lead role in transforming medical practice into a sort of bio-psycho engineering service responsive to the customer's desires -- so long as the customer is willing to pay the asking price. Think of Dr Feelgood...
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