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States Approve Controversial Health Laws

More than just a mandate on the next president, the Nov. 4 national election asked voters in several states to weigh in on controversial health care issues. Washington became the second state in the US (after Oregon) to legalize assisted suicide for terminally ill patients, and Michigan legalized both embryonic stem cell research and the use of medical marijuana for seriously ill patients.

Washington State voters narrowly approved Initiative 1000, with 57.9 percent of the vote. The new law allows mentally competent but terminally ill adults — with less than six months to live — the right to request and then self-administer a lethal overdose of medicine. Two doctors must make independent assessments about the patient's expected length of life before consent for a lethal prescription is allowed.

The law, effective July 2009, explicitly prohibits lethal injections and euthanasia (in which doctors administer the lethal drugs or injections), meaning patients must self-administer oral drugs.

“Ironically, many patients with neurodegenerative diseases [such as amyotrophic lateral sclerosis (ALS) or glioblastoma multiforme, for example] won't qualify legally, because the terminal stages of these diseases often deprive them of the ability to take medication themselves — which is the key distinction between physician-assisted death and euthanasia,” said James Gordon, MD, clinical associate professor of neurology at the University of Washington.

Added Michael Weiss, MD, associate professor of neurology at the University of Washington: “As the patient needs to be competent to make this decision, the measure will not apply to late stage Alzheimer disease.”

Dr. Weiss noted that since the enactment of the Oregon law, only approximately 300 patients have chosen to end their lives.

But Mark Yerby, MD, associate clinical professor of neurology, obstetrics-gynecology, and public health and preventive medicine at Oregon Health and Sciences University, said that many patients in Oregon obtain the medication needed but fail to use it. “They express comfort in knowing they can use it, if their quality of life becomes unbearable,” he said. “The freedom to call one's own shots at such a time is invaluable.”

Dr. Weiss speculated that many neurologists will see this measure as a subversion of the Hippocratic oath and be unwilling to assist because it does not take into account several complex issues. For patients with ALS, the burden falls on physicians to determine when the patient is likely to succumb to the disease, which is increasingly challenging, he said.

“The definition of ‘terminal as six months to live, regardless of treatment’ is a legal fiction, even if it is useful for some purposes,” said Dr. Gordon. “If anything, physicians tend to err to the side of caution when it comes to prognosis: Witness how long we tend to wait before referring to hospice — far too long in many, many cases.”

Among other disadvantages, Dr. Weiss said, the law does not stipulate a mandatory psychiatric evaluation for depression or cognitive impairment, which are not uncommon in ALS patients and obviously influences their decision-making. Also, the act could eventually lead to insurance companies terminating coverage for palliative and hospice care in the state, and there are no obvious safeguards to stop family members or caretakers from coercing patients to take advantage of the law to end their lives.

The law points to the need for greater focus on initiating palliative and hospice care early to alleviate suffering, as well as expanded coverage of such care by insurance companies, Dr. Weiss said. “The Accreditation Council for Graduate Medical Education has recognized such a need by creating a palliative medicine residency program to train physicians who specialize in palliation. The Washington Death with Dignity Actserves only to diminish the immeasurably valuable role of the palliative specialist in caring for the terminally ill.”

Dr. Yerby noted that the recognition and quality of terminal care has greatly improved in Oregon, in terms of greater access to hospice care, more attentive care by physicians, and particularly in terms of better control on chronic pain. “I would hope this would also occur in Washington,” he said.

Before Nov. 4 of this year, Michigan's restrictive embryonic stem cell research law allowed research only on mature stem cells, derived from existing human embryos, or from embryonic stem cell lines created outside of the state.

The new Stem Cell Initiative allows the creation of new stem cell lines from embryos produced in fertility clinics, which would otherwise be discarded (with the consent of the parents), and allows government funding of stem-cell research. It does not overturn the state's ban on human cloning.

Eva Feldman, MD, PhD, Russell N. DeJong Professor of Neurology at the University of Michigan Health System and director of the A. Alfred Taubman Medical Research Institute, said embryonic stem cell research in Michigan could save lives and dollars in health care costs, as well as create jobs in the growing biotechnology industry and at the University of Michigan.

The University of Michigan is a leader in adult stem cell research and home to the Michigan Center for Human Embryonic Stem Cell Research, which maintains nine of the 21 federally approved lines of the pre-existing embryonic stem cells eligible for federal funding.

Michigan voters also passed the Michigan Coalition for Compassionate Care Initiative, which legalizes the cultivation and possession of small quantities of marijuana for terminally and seriously ill people to use for pain and nausea relief. Such debilitating medical conditions include AIDS, cancer, and glaucoma; neurologic disorders include spinal cord injury and advanced multiple sclerosis.

A patient must have a doctor's certification of need, and they are given limits on the amount they could possess — a patient (or caregiver) is allowed to grow up to 12 plants and may possess up to 2.5 ounces of marijuana. There is a mandatory state registration system and registered patients are given identification cards. The law establishes penalties for fraudulent ID cards and false statements, and in the event of an arrest, allows patients to discuss their medical use in court. The Michigan law maintains prohibitions on public use of marijuana and driving under the influence of marijuana.

Michigan is the thirteenth state to legalize medical marijuana. Donald I. Abrams, MD, professor of clinical medicine at the University of California-San Francisco (UCSF) and assistant director of the UCSF Positive Health Program at San Francisco General Hospital, noted that cannabis was widely available by medical prescription in the US until 1942, when it was removed from the US Pharmacopoeia. It is legal for medical use in California.

A 2004 paper in the American Journal of Hospice and Palliative Medicine reported that cannabis can be moderately effective in reducing symptoms of appetite loss, depression, pain, and spasticity in patients with ALS, which has very limited available treatments.

Dr. Abrams conducted a 2007 study in Neurology showing the benefit of smoked cannabis in patients with HIV- related sensory peripheral neuropathy, and noted that some studies suggest that cannabis is beneficial in reducing spasticity in multiple sclerosis (MS). Anecdotally it may benefit migraine or and situations where patients stimulation of appetite, he said.

However, “there is no clear class I evidence that it truly helps,” said Joseph I. Sirven, MD, associate professor of neurology at the Mayo Clinic College of Medicine in Arizona, who commented on marijuana as a therapy for epilepsy and MS in a 2004 Neurology editorial. “I think neurologists as a whole are not convinced that marijuana really helps, so I do not see any many changes occurring with regards to practice or prescriptions.” A few states may follow suit after passage of this law, but not the majority, he said.

The trickiest part of the equation, he said, will be separating those individuals who may truly need the drug versus those who do not. Although Michigan may have legalized marijuana, there is still much more research work to be done to settle the issue as to when or if marijuana should ever be prescribed and for what degree of benefit. “There are still too many questions,” he said.