The Supreme Court's decisions on physician - assisted suicide carry important implications for how medicine seeks to relieve dying patients of pain and suffering.

Although it ruled that there is no constitutional right to physician - assisted suicide, the Court in effect supported the medical principle of "double effect," a centuries-old moral principle holding that an action having two effects -- a good one that is intended and a harmful one that is foreseen -- is permissible if the actor intends only the good effect.

Doctors have used that principle in recent years to justify using high doses of morphine to control terminally ill patients's pain, even though increasing dosages will eventually kill the patient.

Nancy Dubler, director of Montefiore Medical Center, contends that the principle will shield doctors who "until now have very, very strongly insisted that they could not give patients sufficient mediation to control their pain if that might hasten death."

George Annas, chair of the health law department at Boston University, maintains that, as long as a doctor prescribes a drug for a legitimate medical purpose, the doctor has done nothing illegal even if the patient uses the drug to hasten death. "It's like surgery," he says, "We don't call those deaths homicides because the doctors didn't intend to kill their patients, although they risked their death. If you're a physician, you can risk your patient's suicide as long as you don't intend their suicide."

On another level, many in the medical community acknowledge that the assisted-suicide debate has been fueled in part by the despair of patients for whom modem medicine has prolonged the physical agony of dying.

Just three weeks before the Court's ruling on physician-assisted suicide, the National Academy of Sxience(NAS)released a two-volume report, Approaching Death: Improving Care at the End of Life. It identifies the undertreatment of pain and the aggressive use of "ineffectual and forced medical procedures that may prolong and even dishonor the period of dying" as the twin problems of end-of-life care.

The profession is taking steps to require young doctors to train in hospitals, to test knowledge of aggressive pain management therapies, to develop a Medicare billing code for hospital-based care, and to develop new standards for assessing and treating pain at the end of life.

Annas says lawyers can play a key role in insisting that these well-meaning medical initiatives translate into better care. "Large numbers of physicians seem unconcerned with the pain their patients are needlessly and predictably suffering," to the extent that it constitutes "systematic patient abuse." He says medical licensing boards "must make it clear... that painful deaths are presumptively ones that are incompetently managed and should result in license suspension."
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