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Links to the 1997 Supreme Court decisions: Washington et al. v. Glucksberg et al., and USS Vacco v. Quill.
Federal Assisted Suicide Funding Restriction Act of 1997
1992 Angarola RT, Joranson DE. Pain and euthanasia: the
need for alternatives. APS Bulletin
1992;2(2):10,17.
Pain and Euthanasia:
The Need for Alternatives
Robert T. Angarola, Esq.; David E. Joranson, MSSW
Last election day, nearly half the voters in Washington state endorsed a proposal to legalize physician-assisted
suicide. Also in 1991, a Gallup poll found that two-thirds of Americans favored euthanasia for the terminally ill; a
suicide manual became a best seller; and a physician became famous by helping people kill themselves. What accounts
for the strong public interest in euthanasia and support for laws that would allow it?
Role of fear
In large part it is fear: fear of cancer and other debilitating diseases; fear of becoming a burden to one's family; fear
of surviving without really living; and, perhaps most of all, fear of severe, uncontrolled pain. The voters in Washington
and the people polled by Gallup were saying the same thing. They want a law that gives them the right to choose to die
rather than having to live a life destroyed by pain or other circumstances beyond their control.
It is entirely understandable that many people feel this way. Before such laws are adopted, however, there should
be a careful examination of what is being done to address at least one major contributor to patients' fears: pain. In 1990,
a World Health Organization (WHO) Expert Committee found that the greatest improvements in quality of life for
cancer patients and their families would result from implementation of existing knowledge about pain and symptom
management. The committee concluded that "...with the development of modern methods of palliative care, legalization
of euthanasia is unnecessary. Now that a practical alternative to death in pain exists, there should be concentrated efforts
to implement programs of palliative care, rather than yielding to pressure for legal euthanasia" (WHO, 1990). The
WHO Expert Committee recommended that governments, including that of the United States, devote specific attention
to cancer pain relief and palliative care before considering laws allowing euthanasia.
Leadership and education
Indeed, much needed leadership is emerging from state and national organizations in the United States to improve
pain management. These groups include the State Cancer Pain Initiatives, the American Pain Society, the National
Cancer Institute, the Agency for Health Care Policy and Research, the American Cancer Society, the American Society
of Clinical Oncology, the Oncology Nursing Society, the National Association of Oncology Social Workers, and the
Associations of Pediatric Oncology Nurses and Social Workers. Their efforts are beginning to bear fruit. Morphine
and other analgesic use is up; greater professional and public attention is being given to pain management and to
improved training of healthcare professionals, unwarranted fears of addiction, and the negative effect some laws and
regulations have on medical practice and drug availability.
However, state controlled substances laws that govern opioid prescriptions do not recognize clearly that these
medications may be used in the treatment of intractable pain, and some states have erected legal barriers to the
appropriate medical use of controlled substances (Joranson, 1990). A key international regulatory body has called for
all governments to evaluate impediments to proper pain management. The International Narcotics Control Board
(INCB) has issued a special report expressing concern that the availability of opioid analgesics is insufficient to meet
medical needs for the treatment of pain and has asked governments, including the U.S. government, to "...examine the
extent to which their health care systems and laws and regulations permit the use of opiates for medical purposes,
identify possible impediments to such use, and develop plans of action to facilitate the supply and availability of opiates
for all appropriate indications" (INCB, 1989).
In addition, the INCB recommended that "medical instructors and professional associations of physicians, pharmacists, nurses and pharmaceutical manufacturers should be urged to promote rational use of opiates for medical
purposes, bearing in mind their responsibility to ensure that opiates will not be abused" (INCB, 1989).
In the United States today, not enough health professionals, patients, families, and government policymakers
understand that the proper use of existing drugs and neurosurgical, anesthetic, and psychological approaches can relieve
pain and make life worth living. Some people may believe that suicide is the only way to avoid a painful death. Severe,
chronic pain can result in helplessness and hopelessness - two mental states that can lead to suicide. Controlling pain can
help ease these mental states and change the belief that a premature death - a painless "final exit" is the solution. For
example, patients at Memorial Sloan-Kettering Cancer Center who had requested suicide dismissed this as an alternative
once satisfactory pain control was established (Foley, 1991).
At this writing, we know of no U.S. agency that has responded to either the WHO or INCB recommendations on
pain relief. The Department of Health and Human Services should respond to the recommendations of these
international health and regulatory bodies and evaluate the adequacy of current U.S. health policy in addressing pain
and the public's fear regarding pain. This evaluation also should examine the relationship between inadequate pain relief
and euthanasia. The American Pain Society should consider formally requesting such an evaluation.
Derek Humphry, director of the Hemlock Society and author of Final Exit, said that the election day results in
Washington were only the beginning. He expects that physician-assisted suicide proposals will soon be on the ballot
in California and Oregon (Breo, 1991). Ironically, embryonic efforts in the United States to bring pain and symptom
relief to people with cancer and other chronic diseases may be overshadowed by a much more visible movement that
exploits the public's fear of pain but offers only death as an answer. The reality may be that we are closer to having a
national policy on euthanasia than to having one on pain relief.
References
Breo, D.L. (1991). MD aided suicide voted down; both sides say debate to continue. Journal of the American
Medical Association, 226(20), 2895-2900.
Foley, K.M. (1991). The relationship of pain and symptom management to patient requests for physician-assisted
suicide. Journal of Pain and Symptom Management, 6, 289-297.
International Narcotics Control Board. (1989). Demand for and supply of opiates for medical and scientific
needs [Special Report, E/INCB/1989/l/Supp.]. New York: Author.
Joranson, D.E. (1990). Federal and state regulation of opioids. Journal of Pain and Symptom Management,
5, S12-S23.
World Health Organization. (1990). Cancer pain relief and palliative care: Report of a WHO Expert Committee
[Technical Report Series 804]. Geneva, Switzerland: Author.
Last update: January 14, 2000.