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May 1997
Volume 61 |
Number 5
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PRESIDENT'S PAGE
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| Time to Speak
Out! |
Phillip O. Bridenbaugh,
M.D., President
Health care reform, reduced spending and benefits, lower quality
of care and nonmedical decisions related to choices of specialists
and treatments have all been common issues for the daily media
to feed to the public. It would seem that the greatest source
of CME (consumer medical education) today is the television,
newspapers and, yes, the Internet. Most of the time, organized
medicine speaks out only in self-defense or in protest for preservation
of our preferred practice of medicine. In fairness, however, medicine
has also been in the forefront of public health campaigns such
as antismoking and antisubstance abuse (not terribly complex issues
or ones lending themselves to scientific proof).
Over the past few years, discussions relating to the role of
physicians in "end-of-life" circumstances have gained
increasing attention from nonmedical, judicial and social agencies
as well as the media and the public. The combination of a public
threatened with "low cost = low care" health care and
state legislatures attempting to legalize physician-assisted suicide
has made this the media issue of 1997. The matter of a patient's
constitutional right to assisted suicide is now being determined
by the United States Supreme Court, and a decision is expected
sometime late this year. As you may know, the Supreme Court hearings
on assisted suicide last January captured every television and
newspaper headline in America.
As physicians first, then specialists in anesthesiology and pain
management, it is important that we focus on specific aspects
of end-of-life situations as they relate to our practices. Probably
every adult human being in the civilized world has at least thought
about the end-of-life circumstance, whether related to a friend,
relative, family member or personal experience. Naturally, that
includes all of us physicians. To different degrees, religion,
ethics, morality, culture, loved ones, job, economics, legal issues,
etc., will impact on our individual attitudes and desires. However,
as one considers the question of what physician-assisted suicide
has in common with end-of-life circumstances, the common denomination
in a majority of cases is intolerable, unremitting and, fearfully,
unending pain. This clearly is an area where all anesthesiologists
can make a difference.
I titled this discussion, "Time to Speak Out!" Perhaps
it should be "How Do We Help Out?" I say that
because it seems too easy just to speak out. In preparing for
this commentary, I sought out the "sanctuary of the fountain
of unbridled knowledge," the Internet. It is so easy to access
any of several search entities on the Internet, type in the words
"physician-assisted suicide" and click on the search
icon. Low and behold! The Web
Crawler listed 16,266 references and the Excite
search engine generated 327,556 citations. I then clicked on "pain
management" and produced another 107,486 citations. It would
seem that everyone has a lot to say about assisted suicide and
pain management. I suspect ASA speaking out on the Internet would
go unnoticed.
Clearly, pain management is the primary goal of our specialty
- (an = without, esthesia = sensation) loss of sensation.
Analgesia, more specifically, is defined as "absence of sensibility
to pain." Unique among all medical specialties, we in anesthesiology
have the drugs, tools and techniques used daily to provide the
gamut of pain relief from a simple skin wheal to stage III general
anesthesia. I would be doing a major disservice to our physician
colleagues if I implied they were not trained to treat pain because
they all do have to treat pain on a daily basis.
The special characteristics of pain, as part of a terminal disease
state, are unappreciated and usually undertreated by physicians
not used to those circumstances, and often require hospitalization
with special monitoring. Whether it be in an intensive care unit
or oncology unit, specialists in pain management have the invasive
techniques and drugs necessary to make their patients comfortable
and safe. Most are not intimidated at using large doses
of narcotics if that is what is required to obtain patient comfort.
Professor Michael Cousins, M.D., past President of the International
Association for the Study of Pain, was interviewed on Australian
television regarding a state law legalizing assisted suicide.
He noted that in 25 years of pain management practice, he could
recall only four patients who might have opted for assisted suicide
after all options at pain relief and treatment of behavioral side
effects had been exploited. He concluded that government would
be better served to spend its money on treating pain and its associated
sequelae than to spend it on legalizing physician-assisted suicide.
What Can ASA and Its Members Do?
In keeping with most physicians' desires to preserve the autonomy
of the practice of medicine, I would hope all would agree that
federal or state legislators should not dictate how physicians
deal with end-of-life circumstances. I also believe that, to the
degree possible, organized medicine should send to the public,
the lawmakers and the media a strong message reflecting a moral
and ethical practice of medicine, as we took in our Hippocratic
Oath. So what has organized medicine done?
The AMA Program: On August 2, 1996, in anticipation
of the United States Supreme Court's review of physician-assisted
suicide, the American Medical Association (AMA) organized the
"Coalition for Quality End-of-Life Care." This coalition
currently represents 18 medical specialty societies, 13 additional
societies and 25 state medical societies. ASA is a member of the
coalition and is represented by a member of our Committee on Pain
Management. The members of the coalition have agreed to the following
four points as the basis for membership:
- To assist health care professionals with obtaining the education
and training necessary to ensure that patients and their families
receive the multidimensional, compassionate and competent care
they need.
- To articulate the ethics that should govern the relationship
between health care professionals and their patients nearing
the end of life.
- To support health care professionals in keeping assisted suicide
from becoming an accepted or preferred "therapeutic alternative"
for patients nearing end of life.
- To inform health care professionals, the media and the general
public about the dangers associated with condoning a health
care professional's role in assisted suicide.
The primary goal of the coalition is to protect patients nearing
the end of life who are often vulnerable, fearful and in need
of multidimensional, compassionate and competent care. I would
suggest anesthesiologists should endeavor to protect those same
patients from unbearable and unremitting pain due to lack of training,
resources or misunderstandings on the part of the medical team.
Actions of the AMA Coalition: In addition to ASA, members
of the coalition include the American Academy of Pain Medicine,
the American Pain Society and the American Society of Pain Management.
The AMA has several activities planned. First, there was a National
Media Symposium held on April 17 in New York, New York. The symposium
was an educational session for 100 to 150 health care reporters
and other interested media representatives. Other projects include
development of legislative alternatives at the state level in
anticipation of the Supreme Court's negative ruling, and creation
of legislative and regulatory guidelines for end-of-life care
and intractable pain management. It is likely that other activities
will be undertaken subsequent to those noted.
ASA's Role in the Coalition: First, ASA must be an active
player in the coalition, taking a leadership role with media education
and the development of appropriate guidelines for all patients
with intractable pain of such a nature that it creates an end-of-life
situation. If better pain relief by trained, compassionate pain
practitioners can change a patient's outlook, we could start a
new counter initiative called "physician-assisted life."
If anesthesiologists want to improve their image, what better
activity could there be? There are already other media opportunities
for ASA to espouse our role in pain management. Many of you may
have seen the cover article in the March 17 issue of U.S. News
and World Report titled "No Excuse for Pain." Although
a well-written article, the article appended sources for additional
information but made no mention of anesthesiologists. I wrote
a brief letter to the Editor, complimenting the magazine on its
timely article and offering ASA as an additional resource for
public information. Another major media opportunity occurred when
USA Today featured pain management as the subject for its
toll-free hotline on April 16. Readers were urged to call the
USA Today hotline between 9 a.m. and 9 p.m., and their
calls about pain were answered by an anesthesiologist. More than
50 ASA members, at least 10 per the four three-hour shifts, staffed
the bank of telephones and answered callers' questions about pain
management. What a great opportunity for ASA members to be identified
as the experts in pain management!
ASA members are encouraged to use the assisted suicide issue,
the U.S. News and World Report article and the USA Today
articles in letters to their local press.
Finally, I believe it is time for ASA to speak out in the form
of developing a position paper on physician-assisted suicide for
our members to use in reacting to the public and media alike.
AMA and the American Pain Society have already developed such
statements. If this becomes a state legislative issue, any of
our component societies could be asked to take an active role.
Such a position paper would help. I have asked our Committee on
Pain Management to develop a statement for presentation to the
membership. I am certain the committee members will welcome your
input.
Just as anesthesiologists have the opportunity and responsibility
to assist in teaching the public about the hazards of substance
abuse, we also must contribute to the education of the public
that we have something better to offer patients with incurable,
intractable pain than to assist with their suicide. I submit that
hope through better pain relief is the message we should "speak
out!"
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