Mr. Chairman and Members of the Committee:

My name is Dr. Ralph P. Miech. I'm a licensed physician in the state of Rhode Island, a member of the AMA, a member of the American College of Emergency Physicians and a founding member of the Rhode Island Cancer Pain Initiative. I have a Ph.D. degree in pharmacology from the University of Wisconsin. As a full time faculty member of Brown University's School of Medicine, I have been teaching pharmacology to medical students for over twenty five years.

There are several reasons why I wholeheartedly support the Lethal Drug Abuse Prevention Act of 1998 (S. 2151). This bill clarifies the important ethical and legal distinctions between the appropriate medical use of therapeutic drugs for pain control in palliative care and the lethal misuse of such drugs to accomplish physician-assisted suicide. In addition this bill explicitly encourages appropriate drug use for chronic pain control in terminal illness. The difference between medical use and lethal misuse is at the heart and core of the intent of the Controlled Substances Act which I am required to teach to medical students.

Quality pain control in palliative care for the terminally ill involves known drug protocols and regimens that include such things as a step ladder hierarchy of drug selection, appropriate dosages, effective dosage schedules, selective routes of administration and appropriate drug combinations. In the medical literature there never has been any published scientific and peer-reviewed data on how to use these drugs for physician- assisted suicide. Indeed, there are no known protocols or regimens for using these same drugs for physician-assisted suicide. Technically the use of pain control drugs for physician-assisted suicide is categorized as "Off Label Misuse". If the government decided that such misuse could now be redefined as a "legitimate medical purpose" for use of these drugs, each physician would be forced to use a "best guess approach" when deciding which drug and how much of that drug to prescribe for physician-assisted suicide.

Anecdotal information would be used by the physician to select an unknown dose of a narcotic or a barbiturate for physician-assisted suicide. The physician's prescription for a narcotic or a barbiturate to assist a patient in committing suicide causes death by a drug-induced suffocation of the patient. The narcotic or barbiturate paralyzes the respiratory center's control of respiration. The patient stops breathing and the patient dies because of a lack of life-sustaining oxygen. This is equivalent to a physician holding his hand over a sleeping patient's mouth and nose so that the patient is unable to breath.

Oddly, Attorney General Janet Reno in her June 5 ruling said that "the particular drug abuse that Congress intended to prevent (by enacting the CSA) was that deriving from the drug's 'stimulant, depressant, or hallucinogenic effect on the central nervous system,' 21 USC #811 (f)." From this fact she concluded that the Act was not intended to address the misuse of these drugs for assisted suicide. Yet it is precisely by their "depressant effect on the central nervous system: that such drugs stop a patient's breathing and cause death in assisted suicide.

Because the Controlled Substances Act designates narcotics and barbiturates as controlled substances, the use of these drugs must be subject to DEA regulation. The policy choice before the Congress is not whether to regulate them, but how to do so. If assisting a suicide is not a legitimate medical purpose, regulation will take the form of a prohibition for such use. But if assisting a suicide is redefined as a legitimate medical purpose, the DEA must regulate "proper" use for assisted suicide and prevent unskilled or ineffective use for this purpose. If Attorney General Janet Reno maintains that the Controlled Substances Act is unclear on how to regulate assisted suicide, it is the duty of Congress to resolve this question. Congress will fulfill this duty through S. 2151, by stating that assisting a suicide is not an approved medical use for such drugs.

Attorney General Janet Reno has also concluded that any adverse action by the Justice Department is not authorized by the Controlled Substances Act in cases where an Oregon physician assists in a suicide that was in full compliance with Oregon's law allowing such a procedure. Yet statutes in 39 other states have specifically made assisted suicide illegal, and almost all other states treat it under their homicide statutes or forbid it by common law. Physicians in these states who prescribe a controlled substance to assist in a suicide would be in direct violation of the federal Controlled Substances Act. Failure to pass S.2151 will lead to a quagmire of legal entanglements for the Justice Department, because there will be no uniform federal standard for the enforcement of the regulations governing the control of dangerous drugs. The very concept of "legitimate medical purpose" will have diametrically opposed meanings depending on one's state of residence.

The American Medical Association is on record that physician-assisted suicide is not consistent with the goal and philosophy of physician as healer. It is unfortunate that the chief reason the AMA has offered for opposing the Lethal Drug Abuse Prevention Act of 1998 is its fear of intrusion by federal bureaucracy into the practice of medicine. In my opinion, federal protection of public health and safety is not an intrusion of federal bureaucracy into the practice of medicine, but is a proper and a necessary role of good government.

Throughout the recorded history of medicine, physician-assisted suicide has never been recognized as an ethical medical procedure. Any purposeful act by a physician to help cause a patient's death violates the greatest maxim of Hippocrates, "First, Do No Harm". This concept has always been embodied in the Controlled Substances Act, which prohibits the prescribing of controlled substances for a use "which may threaten the publichealth and safety" [21 USC #823 (f)]. Thus from historical, ethical, medical and legal perspectives, the Lethal Drug Abuse Prevention Act of 1998 should be enacted by the US Senate.