ONLINE PHARMACIES

November 17, 1999
		As e-commerce grows, so too do the number of Internet pharmacies. Susan Dentzer looks at the advantages and dangers of allowing drug requests online. The Health Unit is a partnership with the Henry J. Kaiser Family Foundation.

Focus: Internet Rx Nov. 17, 1999: Independent Pharmacies, in on the Act RealAudio extended excerpts with: Ron Klink, Carla Stovall and Eric Thom. Nov. 11, 1999: Hope for the Heart Nov. 9, 1999: What the Doctor Ordered Nov. 1, 1999: Patient Privacy June 26, 1997: Doctor-assisted suicide Browse the NewsHour's coverage of health.   FDA testimony on epharmacies National Association of Boards of Pharmacy cornerdrugstore Web site National Community Pharmacists Association	KWAME HOLMAN: After an often-passionate debate, the House today approved a bill that would outlaw the dispensing of federally-controlled drugs, such as morphine, if they are to be used to help a patient commit suicide. Opponents said it effectively would overturn a 2-year-old Oregon law that permits physician-assisted suicide. The bill would encourage doctors to prescribe powerful drugs to alleviate a patient's pain even if the unintended result is death. But health care professionals who prescribe controlled substances with the intent of hastening a patient's death would face jail sentences of up to 20 years. REP. TOM COBURN, R-Okla.: The real thing that we're going to be debating is about life, and as the freest nation in the world, are we going to abandon the principle that life has value? KWAME HOLMAN: During today's debate, opponents said the measure would have an impact far beyond outlawing Oregon's assisted suicide law. They said it would make doctors across the country fearful even of prescribing standard doses of drugs for pain relief. Under the bill, the federal Drug Enforcement Agency would be charged with monitoring doctors' compliance. REP. STEVEN ROTHMAN, D-N.J.: So what does the underlying bill do? It provides for a criminal penalty against doctors, 20 years in jail maximum. What you have here is obvious; doctors are conflicted, they're afraid. REP. HENRY HYDE, R-Ill.: It comes down to this: Do we want to empower our doctors to intentionally kill a patient even if that is the desire of the patient or the family? Do we want to add executions to the list of healing services they provide? Should Oregon law trump the federal law? KWAME HOLMAN: Oregon's assisted suicide law, known as the Death with Dignity Act, took effect in 1997 after the state's voters supported it in two ballot initiatives. In Oregon, a terminally ill patient who requests it may be prescribed a lethal dose of drugs if two doctors concur that the patient is likely to die within six months. Only the patient may administer the drugs. A report by the Oregon Health Department says 23 terminally ill patients were prescribed lethal drugs last year and 15 of them used the medications to end their lives. In the last several years, pro- assisted-suicide ballot initiatives have failed in Michigan, California and Washington state. In fact, more than 40 states have laws that explicitly ban assisted suicide. The U.S. Supreme Court, in a 1997 ruling, said while there is no constitutional right to die, the states may continue to debate the issue. SPEAKER PRO TEMP: The recorded vote has been requested. KWAME HOLMAN: In its vote today, the House approved the anti-assisted suicide measure by a comfortable 271 to 156 margin. The Senate could take up a similar bill as early as next month.
	A question of pain management or states' rights?
	GWEN IFILL: A leading supporter of the House bill and an Oregon state official join me to debate today's action. Republican Congressman Dave Weldon of Florida is also a practicing physician. David Schuman is deputy attorney general of Oregon and professor of constitutional law at the University of Oregon. Congressman Weldon, the Supreme Court, as Kwame Holman noted in his piece, ruled a couple of years ago that, in fact, this is not, this should be a question for the states. They say there is no constitutional right to die, but it should be debated at the public policy level. Why then would Congress intervene? REP. DAVE WELDON, R-Fla.: Well, the U.S. government has authority over the prescribing of controlled substances, while the states like Oregon do have the right to provide doctors who are properly credentialed a license to practice in the state. The federal government controls another type of license called the DEA license, which gives the doctor the authority to write prescription drugs such as morphine, controlled substances. GWEN IFILL: DEA meaning Drug Enforcement Administration? REP. DAVE WELDON: Right, and what we're saying in this act is that using these drugs for this type of purpose is not consistent with the Controlled Substance Act which was the original legislation that governs this whole arena. And it's really not because most medical societies have come out very strongly in opposition to physician-assisted suicide, and it is not within the recommended usages of these drugs, and probably the biggest reason why I personally feel very strongly that we should move in this direction -- is having taken care of a lot of patients who were dying with terminal illness, I never saw a case in competent hands where the patient's suffering could not be properly managed with existing drugs, and I think to hold out suicide as a necessary option is really a hoax. I never saw a case where you could not deal with the suffering of patients, with the medicines we have available today, which are excellent drugs. GWEN IFILL: And for you, congressman, that's a compelling enough reason to override a state law voters of Oregon voted twice for? REP. DAVE WELDON: I certainly believe it is. I believe the evidence is very, very clear that most people who approach a doctor with a request like this are usually not being managed correctly. Their pain drugs are not being given at a sufficient dose or they are suffering from depression and there are excellent medications available for that, or they have some social problems existing within their family, and often all it really takes is a really caring and compassionate physician who knows how to use the drugs properly and is willing to invest his or her time in their patient to deal with these issues and to reach out and say we need to help you with your suicide to me is -- it is a bankrupted and empty solution. It's really, in many ways it is a lazy way out. GWEN IFILL: Mr. Schuman, as the deputy attorney general of Oregon you clearly have been put in the position where you have to enforce the referendum that Oregon voters pass. What is the reaction to today's House vote? DAVID SCHUMAN, deputy attorney general, Oregon: Well, we think if the people of Florida agree with the congressman, they are perfectly free to enact a statute that criminalizes physician-assisted suicide. People of Oregon, as you've noted, have twice voted in favor of permitting resident adult terminally ill competent Oregonians to receive a lethal prescription to end their life with dignity. Our position is, that that's a valid and legitimate choice for the Oregon voters to have made and that it's not the sort of decision that should be overridden by Congress. And, in fact, in enforcing the Controlled Substances Act, Congress has the authority to regulate the traffic in narcotics and -- as the legislative history of that act says -- to address the growing menace and drug addiction and drug abuse. None of that has anything to do with regulating the profession of medicine in the state of Oregon. That is a matter for the people of Oregon to decide, and they have decided it. And they have decided it twice, and that should be the end of the question.
	An unethical use of drugs?
	GWEN IFILL: Congressman Weldon, you talked yourself a moment ago about pain management and about the degree to which doctors should be trying to manage pain instead of giving people an option to take their own lives. As it stands now, the only difference between a doctor who decides to prescribe medication for pain management and a doctor who describes a medication for pain management which results in a patient's death is that doctor's intent, whether the doctor intended for the person to commit suicide or not. Who decides when it comes to prosecuting this law -- who decides what the doctor's intent was? REP. DAVE WELDON: Luckily, under the Oregon statute the patient has to approach the doctor and say verbally they want to end their life, kill themselves, and the doctor is supposed to record that in the chart, and then the patient is supposed to come back 15 days later and reiterate that request and I believe they're also supposed to put it in writing and the doctors are required to keep all this in the records. And my argument is that is a medically unethical use of those drugs. It's unethical for a doctor to say, "Yes, your condition is so bad you need to die and I'm going to cooperate with that" -- notwithstanding the Oregon referendum. I as a professional argue that that is -- it's a hollow and bankrupt and medically incompetent thing for a doctor to do that knowing what I know. There are pain relievers available not only in pill form and intravenous form, in suppository form, they have transcutaneous patches, it's absorbed through the skin. There is even a lollipop available. I've never been unable to relieve somebody's pain. It's actually getting easier as time goes on to manage these patients, not harder. Likewise for depression, most of these people are very depressed, and there are excellent, excellent drugs on the market. GWEN IFILL: Mr. Schuman, I just want to bring you back in here for a moment. Is this something that in the two years it's been as part of law in Oregon, has there been a stampede of doctors. We heard there were 15 people who choose to take their lives under this law? DAVID SCHUMAN: Hardly a stampede. It hardly opened the floodgates, and I think it bears restating that the congressman misses the point. The point is not whether or not physician-assisted suicide is an ethical use of controlled substances. The point is whether or not Congress has the authority to tell the citizens of Oregon that they can't regulate the medical professional within their own state. That is something that simply is not within a constitutional competence of the federal government. That's the issue here. If we want to talk about the issue of palliative care and relief of pain, this statute will have a perverse effect. It will make doctors extremely nervous about taking aggressive palliative measures because if in fact some Drug Enforcement Agency officer looking at the charts decides what the doctor's intent was and decides that the doctor's intent was to hasten death, then the doctor is looking at 20 years in federal prison. When the doctor is faced with a choice of aggressively treating pain or not aggressively treating pain if the doctor sees in the background a Drug Enforcement Agency prosecution, it seems to me that the doctor is going to back off. And that's what we're hearing from doctors in the state of Oregon and around the country. The fact of the matter is the medical profession is profoundly split over this issue. The Oregon Medical Association -- REP. DAVE WELDON: I would like to respond to that if I might. GWEN IFILL: Just a moment. DAVID SCHUMAN: -- supports the Death With Dignity Act.
	A question of constitutional authority?
	GWEN IFILL: Congressmen Weldon, you can respond. REP. DAVE WELDON: Well the AMA supports this act. There is an important provision in the act that says that if the doctor is treating the patient for pain even if that treatment results in a hastening of death, that that's OK. But it goes on to very specifically spell out using language that has been employed in many states that if it's specifically being used to assist in a suicide, that that is not allowed under the provisions of the act. GWEN IFILL: What about the state's right issue that Mr. Schuman brings up? Is this a question of the federal government intervening unnecessarily in an issue that should be left to the states? REP. DAVE WELDON: Well, you know, the federal government intervenes in a lot of issues. A good example is the Motor Voter law. That, most states controlled how people register to vote, and the federal government came along and did that. We certainly have other provisions, such as provisions in our Constitution against slavery. So there is lots of examples where the federal government steps in. I think it's appropriate to do that in this situation, because the reason the AMA supports the bill, the reason the Hospice Association supports the bill, is because most clinicians know that this is not necessary. You don't have to allow people to kill themselves. You can get involved and manage them correctly and avoid that type of a gruesome option. GWEN IFILL: Mr. Schuman, a brief response. DAVID SCHUMAN: The question isn't whether or not this is something that is appropriate for Congress to do or something that would be a good policy decision on the part of Congress. The question is whether or not Congress has the constitutional authority to do it. And the way the Supreme Court has recently been interpreting Congress's authority under Article I of the Constitution, this isn't within it. GWEN IFILL: Congressman Weldon and Mr. Schuman, thank you both very much. DAVID SCHUMAN: Thank you.