Dr. Paul Bilder may never become a famous name in the history of end-of-life care at the end of the millennium.
Bilder is no Jack Kevorkian, the pathologist who brazenly defied the law and forced the country to deal with assisted suicide. Nor is he Timothy Quill, the internist whose published admission that he helped a terminal patient die encouraged other doctors out of the closet.
But Dr. Bilder represents a landmark nevertheless. This month, the Oregon pulmonary specialist became the first doctor in the country to be disciplined by a state board of medical examiners for undertreating pain in his patients.
The patients in his "care" were not all dying, but some experienced the kind of suffering that could have been alleviated -- and wasn't. Once, Bilder prescribed only Tylenol for a terminally ill man with cancer. Another time, he gave a patient only a fraction of the drug that the patient needed and the hospice nurse suggested. He refused morphine or similar pain medication for an 82-year-old with congestive heart failure.
After being challenged on this mistreatment, Dr. Bilder signed an order admitting that he showed unprofessional or dishonorable conduct and negligence.
It's not a surprise that the first such case in which a doctor is taken to task for undermedicating pain and suffering happened in Oregon. The state was after all, also the first in the country to pass a law legalizing doctor-assisted suicide.
Even those who deeply oppose such legislation acknowledge the good news about the ethical wrangling over the end of life. We have finally embarked on a long-delayed discussion about the need for palliative care, for compassionate treatment, for understanding the real experience of illness.
Indeed in the same week that Dr. Bilder was disciplined for failing his patients, the British medical journal Lancet published a Canadian study showing that, even among terminal cancer patients, the will to live fluctuates a great deal. In the course of just one day, attitudes toward living and dying change. This research shows what common sense suggests: Physical pain affects attitudes about living and dying.
Yet even in Oregon, as a recent study from the Center for Ethics in Healthcare showed, a third of people in the last week of life suffer moderate to severe pain. If pain is behind despair, if pain is the primary rationale for supporters of doctor-assisted suicide, how much of the ethical debate is really a medication debate?
The irony of this controversy is that 20 years ago, doctors were penalized for giving too much medication -- specifically narcotics.
In the early 1980s a pain specialist was accused of overprescribing by the California medical board. Just last February another California doctor was charged with murder. The prosecutor said that he was really supplying drugs to users.
For a long time, our paranoia about drugs and addiction, especially narcotics, has affected the fear and freedom that doctors have to ease pain. We have acted as if a terminally ill 80-year-old patient were a junkie about to rise from her death bed and rob a grocery store. We still deny marijuana for AIDS and chemo patients. We deny heroin to the dying.
The War on Drugs has done its collateral damage on sick civilians. But now in Oregon a doctor is also disciplined for prescribing Tylenol when the patient needed morphine.
This is not just damned if you do and damned if you don't. We are again in a time of change.
The health community is gradually adopting standards that recognize a right to pain management. Nineteen states now have laws that protect doctors from prosecution for prescribing painkillers as long as they are used to kill pain. And Oregon has, at last, stated that good care means reducing suffering.
In the end, the most important part of Dr. Bilder's "punishment" requires him to learn how to listen to patients. In the midst of a national debate about a doctor's role in providing a compassionate death, what he'll hear is the desire for just plain compassion.
(C) 1999, The Boston Globe Newspaper Co.