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Considering assisted suicide // First, guarantee care, then discuss help in dying

Anyone who has cared for a terminally ill patient or even visited a nursing home knows that the process of dying is rarely cost-effective.

And anyone familiar with the market pressures changing the landscape of American health care knows that cost-effectiveness now drives more medical decisions than we like to admit.

Therein lies one of the dilemmas of physician-assisted suicide _ one not touched on in two recent decisions from federal appellate courts overturning long-standing bans on the practice.

It is one thing for a relatively homogeneous society like the Netherlands, with guaranteed health-care benefits and stable relationships between patients and their doctors, to accommodate decisions in which those doctors can agree to their patient's wishes to hasten death, provided a number of safeguards are observed.

It is entirely another matter to attempt to provide safeguards against abuse in a country where access to medical care is tenuous, where the cost of care can be a huge burden to families and where increasing numbers of patients have no continuity with the doctors who treat them.

As Arthur L. Caplan, head of the center for Bioethics at the University of Pennsylvania, puts it, "I've never met a poor person, a person who lacks medical insurance or someone on Medicaid who is also a member of the Hemlock Society" _ a prominent right-to-die group that advocates legalizing physician-assisted suicide.

It is absurd, Caplan argues, for a country to carve out a right for a person to seek a physician's aid in hastening death, before assuring minimal access for that same person to seek a physician's treatment. No country can rest easy about adequate safeguards for assisted suicide when it has 30-million people uninsured and another 20-million who lack adequate insurance.

Caplan is among those who worry about judges deciding these issues. He would prefer to see the issue taken up by the political process. The result might well be the same, but at least it would be imposed by voters in the election booth, not by a few figures in robes.

Oregon has legalized assisted suicide through a referendum. California and Washington have come close, and may yet succeed. Not all citizens are happy with the consequences, but they cannot quarrel with the democratic way in which the decision was reached.

The political process gives every citizen a say. It also gives voice to the concerns of physicians like Stuart A. Grossman, director of neuro-oncology at the Johns Hopkins Oncology Center and a specialist on cancer pain.

Grossman points out that we are rarely able to stop people from dying when they really want to end their lives. If they are determined to die, they usually find a way to succeed.

But in his experience, many cancer patients who say they want to die don't really mean it.

"What they are usually asking for," Grossman says, "is a glimmer of hope. They don't know what to ask, so they ask to die."

Once patients get some help, whether for pain control, depression or some other problem, "they come back and thank us for addressing the issues," he says.

His fear is that physician-assisted suicide could become a shortcut, taking the attention away from the need to provide adequate care for symptoms so that patients can remain comfortable.

That is possible in all but the rarest cancer cases. "When I hear of somebody who ended their life because of pain, I get goose bumps," he says.

Pain and suffering is only one trouble spot for those worried about the dilemmas posed by physician-assisted suicide. The abysmal state of long-term care _ both quality and cost _ in this country raises its own warning signs. Ask yourself, as Caplan does, "Would you rather spend three months in a prison or in a nursing home?" Your hesitation in answering tells volumes about this part of our health-care system.

Until we can assure good long-term care and provide insurance for it, until good hospice programs are widely available, and until we reduce the cultural and ethnic distrust spurred by a health-care system inaccessible to many Americans, carving out a right to physician-assisted suicide will create more problems than it solves.

That is not to say that physician-assisted suicides are always bad. But without adequate safeguards _ the kind best hammered out in the political process _ there will always be nagging doubt that all the people who might choose it really understood their options.

Sara Engram is deputy editorial-page editor of the Baltimore Sun.

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