Assisted suicide a decision for the states

The question of whether physician-assisted suicide is a "legitimate medical practice" remains open to debate but, said a three-judge panel from the U.S. 9th Circuit Court of Appeals, U.S. Attorney General John Ashcroft can't be the final arbitrator.

In a 2-1 ruling May 26, the judges reaffirmed that states were responsible for regulating the practice of medicine and not the U.S. Dept. of Justice -- except in cases where Congress provided "unmistakably clear" authorization. The majority said Ashcroft did not have this authorization when he threatened to revoke the licenses to prescribe controlled substances of Oregon doctors who wrote lethal prescriptions as part of the state law allowing assisted suicide.

Dept. of Justice spokesman Charles Miller said no decision had been made regarding what step the Bush administration would take next, but added that it had 45 days to appeal the decision to a larger panel of 9th Circuit appellate judges or 90 days to appeal to the U.S. Supreme Court.

Salem, Ore., oncologist and hospice physician Peter Rasmussen, MD, was a plaintiff in the case. He said he hoped the decision would be appealed. "The more times this goes through judicial review, the more solid the foundation of legality becomes," he said.

The justices, however, avoided ruling on the legality of assisted suicide.

"To be perfectly clear, we take no position on the merits or morality of physician-assisted suicide," the ruling states. "We express no opinion on whether the practice is inconsistent with the public interest or constitutes illegitimate medical care. This case is simply about who decides."

They ruled that states were the primary regulators of professional conduct, and Ashcroft's directive interfered with a practice specifically authorized by Oregon law.

"This was a constitutional ruling and not a ruling on the issue itself," said Michael Fleming, MD, president of the American Academy of Family Physicians, saying the issue is of concern to his group because most end-of-life care (especially outside large cities) is provided by family doctors.

"We don't support assisted suicide," he said. "What we support is our doctors and their patients having frank discussions about pain relief and measures that can provide a better quality of life at the end of life."

The AMA, which opposes assisted suicide, didn't comment on the ruling.

Ruling does little to stem debate

Physicians for Compassionate Care President Ken Stevens, MD, expressed disappointment and said the intent of the Controlled Substance Act was to prevent misuse of drugs and that suicides were specifically identified by legislators as such a misuse.

"If Oregon or any other state can remove itself from federal statute, then the United States won't be able to have a unified drug policy," said Dr. Stevens, chair of the Radiation Oncology Dept. at Oregon Health & Science University.

Frank James, MD, of Molalla, said his mentor, Allison Willeford, MD, who championed assisted suicide and died after discontinuing dialysis, would have been pleased. "He'd be happy because he wanted to have the choice to do what he wished and wanted others to be able to shorten their lives if they weren't going to get better," he said. "But it's not like everyone is rushing out to do themselves in. The only time you hear about it is when there's a court ruling."

One group, however, feels there is a serious concern that's not getting discussed: that the "right to die" will evolve into an obligation to die, as persons dependent on others to provide and pay for their care will be made to feel it would be better to commit suicide than continue to be a burden to family, friends and society.

"People with disabilities are a minority group subject to a history of discrimination and oppression," said Diane Coleman, president of Not Dead Yet, a national disability rights group. "The feds are needed to step in to provide protection from local prejudice."

Under Oregon's Death With Dignity Act, lethal prescriptions can be written for adult Oregon residents who have been diagnosed by two physicians as mentally competent and having six months left to live. Since assisted suicide became legal in 1998, 171 deaths have been reported.

Coleman noted that major reasons cited for taking lethal prescriptions include: losing autonomy, losing control of bodily functions and being a burden. "The statute was set up to say 'If you need too much help, if you're a burden on your caregivers, it's fine with us if you take the other way out,' " she said.