The NewsHour with Jim Lehrer

MR. LEHRER: Good evening. I'm Jim Lehrer. On the NewsHour tonight, a unabomber update, Elizabeth Farnsworth de-briefs two reporters; doctor-assisted suicides, Lee Hochberg reports from Oregon, Margaret Warner runs a debate; and part one of a week-long series on health care costs. Fred De Sam Lazaro reports on an experiment in Tennessee. It all follows our summary of the news this Monday. NEWS SUMMARY

MR. LEHRER: Federal prosecutors met in Washington today on how to proceed in the unabomber case. The meeting was with Justice Department officials. Also, a lawyer for the brother of the unabomber suspect called a news conference in Washington. He said David Kaczynski grew suspicious of his brother, Theodore, because of certain similarities between his writings and those of the unabomber. We'll have more on the unabomber story right after this News Summary. Overseas today, ethnic fighting broke out in the African nation of Liberia. A U.S. military assessment team was flown from Sierra Leone to survey the situation. Early reports said thousands of Liberians fled the capital of Monrovia after the fighting started over the Eastern weekend. A State Department spokesman said 10,000 people took refuge at various U.S. embassy sites in Monrovia.

STATE DEPARTMENT SPOKESMAN: The situation in Monrovia continues today to be chaotic. This follows on a couple of days of widespread looting and fire throughout the capital. Thousands of Liberians appear to be fleeing the city. The United States made a decision recently that it was prudent to make contingency plans to protect the lives of U.S. citizens, both official Americans and private citizens who are in the country. We haven't made any decision yet to evacuate anybody from, from Monrovia, nor have we made any decision about the U.S. embassy and whether it will remain open.

MR. LEHRER: There are about 450 American citizens in Liberia. On the Korea story today, White House spokesman Mike McCurry said the U.S. does not foresee fighting breaking out in the demilitarized zone. South Korean soldiers on high alert patrolled their side of the DMZ today, following three incursions by North Korean forces. News reports said South Korean troops would be ordered to shoot North Korean forces setting foot in the Southern half of the DMZ. Defense Secretary Perry described North Korea's intrusions as a provocative action, but he said North Korea's economic problems are of even greater concern.

WILLIAM PERRY, Secretary of Defense: The North Korea economy is in terrible shape now. It's so bad that there's really not enough food distributed to feed all of the people, and this is causing, as you can imagine, tremendous tensions or conflicts within the country. And we have a continuing concern that the government in North Korea might respond in some sort of an irrational way to the problems they see in trying to simply keep themselves, keep their regime in power.

MR. LEHRER: South Korea is in the final stages of a general election campaign that ends with a vote on Thursday. In Croatia today, U.S. Air Force investigators checked the navigation system at the Dubrovnik Airport. A member of the National Transportation Safety Board is part of that investigating team. They are looking for the cause of the plane crash that killed Commerce Secretary Ron Brown and 34 others last week. Both American and local officials have said the 50-year-old navigation system at the Dubrovnik Airport is reliable. In Bosnia, Bosnian Serb authorities said today they would free three war prisoners that continue to hold sixteen. The Serbs say those men are suspected of being war criminals. Back in this country on Wall Street today, the Dow Jones Industrial Average fell 88 1/2 points. It was down 140 points at one time during the trading day. Analysts said it was triggered by Friday's strong employment report from the Labor Department. They said good employment news usually means the Federal Reserve will not lower interest rates. And in Washington today, President and Mrs. Clinton hosted the annual White House Easter Egg Roll. Thousands of children and their parents took part; so did costumed characters, including the Easter Bunny, who roamed the South Lawn of the executive mansion. The event has been a Washington tradition for 187 years. And that's it for the News Summary tonight. Now it's on to a unabomber update, doctor-assisted suicides, and part one of a new series on health care costs. UPDATE - THE UNABOMBER?

MR. LEHRER: We do begin tonight with an update on the unabomber story. Elizabeth Farnsworth has more.

MS. FARNSWORTH: Federal prosecutors from several states met in Washington today at the Justice Department. They discussed how and where they would prosecute the case against Theodore Kaczynski, the prime suspect in the unabomber case. Over the course of 17 years, the unabomber is alleged to have mailed bombs to 16 locations in nine different states, resulting in three deaths and twenty-three injuries. The 53-year-old Kaczynski continues to be held without bond in a Helena, Montana, jail. Also in Washington, D.C., today, the attorney used by the brother of Theodore Kaczynski to contact the FBI about the family suspicions held a press conference.

ANTHONY BISCEGLIE, Washington Lawyer: Let me begin by reading to you all a statement written by the Kaczynski family. "Our hearts are with Ted. Our deep sympathies go out to the victims and their families. We will not be speaking with anyone from the media now or in the future."

MS. FARNSWORTH: Anthony Bisceglie described David Kaczynski's growing fear that his brother might be the unabomber, especially after a 35,000-word manifesto was published by the "Washington Post" and "New York Times" last Fall.

ANTHONY BISCEGLIE: I would say in the late summer, Mr. Kaczynski, Mr. David Kaczynski and his wife had heard some of the media reports about the various locations used by the unabomber or related to the unabomber. There was a nagging feeling that their brother, Ted, had some connection to those locations, but it was dismissed. When the manifesto was published, David Kaczynski read the manifesto with the idea that he would be able to immediately discount any connection between his brother and the unabomber. Unfortunately for Mr. David Kaczynski, when he read the manifesto, he was unable to do that and, in fact, was left with considerable unease.

MS. FARNSWORTH: David Kaczynski sought health from an investigator, a security consultant, and attorney Bisceglie.

ANTHONY BISCEGLIE: After discussing the matter at some length and reviewing the materials and getting additional letters authored by Ted, I determined also that there was a significant possibility that Ted and the unabomber were one and the same. On that basis, I obtained David Kaczynski's consent to contact the FBI.

MS. FARNSWORTH: Bisceglie described the Kaczynski family's painful decision to come forward with information.

ANTHONY BISCEGLIE: I think there was a great deal of anguish, and I think now there is a great deal of grief, and this family is going through a grieving process. Mrs. Kaczynski was not informed about this investigation by us or anyone else until about two weeks ago when the investigation reached a stage where it was necessary to inform her. Her reaction was amazingly strong. She expressed her sincere belief that Ted could not be the unabomber, but she also stated that if he were, then he had to be stopped. There was further limited contact between David and Ted over the years, over recent years. There was correspondence. David had not seen Ted for six years, so there was a great deal of unknowns about Ted. There were certain things that we did know. We knew that Ted was a loner. We knew that Ted lived without electricity or plumbing. We knew that Ted was very much opposed to technology. We knew that Ted lived the lifestyle of wild nature that is described as the optimum condition of living in the manifesto. I think there was tremendous dismay. This is an extremely difficult situation for a family member. This is a close, loving family. I think David wanted very much to believe that Ted was not involved, and, and still would like to believe that.

REPORTER: And what does he believe now?

ANTHONY BISCEGLIE: I think he is somewhat in shock.

REPORTER: Does he think that his brother is the unabomber?

ANTHONY BISCEGLIE: I think that he believes that his brother is involved.

MS. FARNSWORTH: Bisceglie denied reports that the Kaczynski family had bargained with the FBI.

ANTHONY BISCEGLIE: I did see a report that suggested that I proposed as a condition for disclosure that the death penalty be waived in this case. That discussion did not take place. I think there is a concern for Ted's welfare expressed by the family that is consistent with any ultimate sentencing if there is a sentencing in this case. But I was, I neither demanded nor was rebuffed on that issue, and as I'm sure you understand, that is something we would have no control over in any event.

MS. FARNSWORTH: Bisceglie said the family was not motivated by the possibility of a $1 million reward being offered by the FBI.

ANTHONY BISCEGLIE: Well, I can tell you this. Neither David Kaczynski nor myself were aware that there was any reward at all when we contacted the FBI. Umm, money was absolutely not an objective in this case. I have no knowledge of what the status of the reward is, and I've made no inquiries in that regard. There's a possibility that reward moneys are made available to the families of victims.

MS. FARNSWORTH: Now, two reporters who have covered this story for some time. David Jackson is the San Francisco bureau chief for "Time" Magazine, and John O'Brien is a reporter with the "Chicago Tribune." Thank you both for being with us. John O'Brien, the family's decision to come forward is clearly what broke this case, right?

JOHN O'BRIEN, Chicago Tribune: [Chicago] It does appear to be that way, Liz. Contrary to some reports, the name of Ted Kaczynski was not known to investigators in this particular case.

MS. FARNSWORTH: And give us the--describe for us what happened in Chicago. They found something in the home that's in Lombard, near Chicago, right, and that gave them the, the search warrant, what they needed to get a search warrant in Montana?

MR. O'BRIEN: They--what they found last month at the old Kaczynski home in Lombard, Illinois, together with other information passed on to the family enabled the FBI agents to establish probable cause with which to obtain a search warrant, and that warrant was, in turn, executed at the cabin in Montana.

MS. FARNSWORTH: What did they find?

MR. O'BRIEN: Well, they found compounds commonly used in explosives. They found some trace elements of gunpowder, and they found some writings, indications of--of instructions on how to make devices. It's believed that, that Ted Kaczynski may have used items in that shed to construct the first four devices which were later described as amateurish and which convinced authorities that they might be dealing with someone much younger than Ted Kaczynski.

MS. FARNSWORTH: Have they matched anything that was found in the home in Lombard with any of those--there were four--the four LA bombings?

MR. O'BRIEN: They have found some common characteristics in those four devices. The first two were incendiary in nature, along with what was found in the shed. For example, they found some very old wooden match sticks. In the first two devices, match sticks were used, fused together so as to create a sudden flash of flame upon opening the devices. They were concealed in packages sent to targets of the, of the unabomber.

MS. FARNSWORTH: And Dave Jackson, would you give us an update on the investigation in Montana. What has been found there?

DAVID JACKSON, Time Magazine: [San Francisco] Well, as we know from the affidavit last week, Elizabeth, they found quite a cache of materials that were very incriminating for Ted Kaczynski. There were not only pipes that were in the process of being made into bombs. They were sealed at one end, which is one of the stages that you go through when you're constructing a pipe bomb, but they also found chemicals that could be used in explosive materials and they found a lot of notebooks.

MS. FARNSWORTH: Let me interrupt you just for a second, Dave. The pipes were sealed at one end that they found in Montana and that was like the bombs that they had found--the bombs that went off, right?

MR. JACKSON: Well, to make a pipe bomb, you have to seal it at one end, and they know a lot about how the unabomber sealed his pipes at one end, and we understand that there are some similarities between the unabomb bombs and the ones found in, in- -under construction up in Montana. They also found a lot of writing materials. They found things such as notes that he had taken on his experiments to determine the best way to create an explosion in different weather conditions, and these are very incriminating.

MS. FARNSWORTH: What about the carved boxes? Some of the bombs- -there's a tie--carved boxes in the bombings and also found in his place, right?

MR. JACKSON: He used, uh, he used boxes in several of his devices. He used wooden initiators, carefully carved wooden initiators in several of his bombs. These are trademarks of the unabomber, and there is a report that he--that they found carved boxes in Montana. We have to keep in mind that almost all of these reports are unconfirmed officially, but the Feds simply aren't saying, so we're having to rely on a lot of, umm, reports from people who are being very cautious about what they're revealing, and very little of it has been confirmed officially yet.

MS. FARNSWORTH: Just based on what you know and what has been confirmed officially, how damning do you think this is so far?

MR. JACKSON: I think it's a very strong case against Ted Kaczynski as a bomber. There's been not that much evidence that's been made public yet showing that he is the unabomber. Clearly, he had bomb-making materials in his cabin in Montana. They're now trying to put together physical evidence and witness testimony to show that he also was in places where the unabomber left bombs or sent bombs. They have handwriting samples now that surely are going to be very helpful. There's a report even that they have a suspicion of whom these new bombs in Montana were intended for. If that's the case, uh, it would be very useful for the investigation because up to now we really don't know how he chose his victims. And if they have the names of victims in--from the evidence in Montana, this could really help solve the mystery of how these people were chosen for the last 18 years.

MS. FARNSWORTH: John O'Brien, do you have anything to add to what we're discussing here, and especially about whether this evidence- -and I understand that there's much that we don't know and much that isn't official--how much, how damning it is?

MR. O'BRIEN: Well, let me just follow up on David's observation and point out that authorities have established that, that Ted Kaczynski was in the Chicago area at four crucial times when the first four devices were sent through the mail or detonated. Now, this was at a time when he had already established residence in Montana. He was back in the Chicago area ostensibly to earn money to continue his lifestyle in the mountains, but he was also here at a time when these devices were--came to the attention of authorities, and I think that's a very strong circumstance against him.

MS. FARNSWORTH: It's clear that they're trying to put together the bombings in his travels. And they--there seems to be some progress in that, right?

MR. O'BRIEN: Yes. For example, hotel people in California, David was certainly noticed, had established that he had been a guest in some, some hotels at times when devices were found in that state.

MS. FARNSWORTH: David, do you have anything to say about that? Is that again just leaks, or have reporters talked directly to those people?

MR. JACKSON: Reporters and law enforcement agents are out in force in California. There are, there are witnesses in both Berkeley and Sacramento who are now telling reporters that they recognized the picture of Ted Kaczynski. Unfortunately, Ted Kaczynski right now looks like every other guy living on the street, but they--I'm sure they've got some names that they're looking for. I'd be surprised if Ted Kaczynski used the same--the same assumed name in all of his visits. He was a very--if he is the unabomber, the unabomber was a very cautious person, and I'm sure that it's not a simple matter of going around and saying, do you have any record showing a man named Ted Kaczynski stayed here?

MS. FARNSWORTH: I want to ask you both this question but starting with you, Dave Jackson, you've covered this for a long time, and you have speculated on what the unabomber must be like I'm sure many times. Does what you know about Mr. Kaczynski fit what you thought the unabomber would be like?

MR. JACKSON: So far, everything that's come out, Elizabeth, has been remarkably supportive of the profile that they created. They suspected it was a person who was very meticulous, who kept lists even. They found these lists that were amazingly detailed in his cabin. They predicted a person who would be a social outcast, who would have very little dealings with people, someone who'd be able to disappear for weeks or days and weeks at a time and no one noticed. Ted Kaczynski fits that profile. They even surmised that he may shun technology, and here's a guy who, except for one brief period of time, didn't even drive a car. He got around on a bicycle. So all these things don't make you a unabomber, umm, but they, they certainly don't, umm, tend to exonerate Ted Kaczynski as asuspect. The case looks pretty strong at this point. And privately, investigators are saying that they feel very confident that they've got their man.

MS. FARNSWORTH: John O'Brien, do you have anything to add to that? You've been working on this case since 1980, haven't you?

MR. O'BRIEN: Yes. When the fourth device seriously injured Percy Wood, who was then president of United Airlines. I would just add that I would agree with what David has said. The "Tribune", "Tribune" reporters Gary Marx and Bob Secore, however, have established one exception to the profile, and that's the age of Ted Kaczynski. Most investigators pegged him for at least ten years, maybe eight to ten years less than fifty-three, and there's some reason to believe that because of the age difference, i.e., his age and the age on the profile, that, that investigators might have missed an opportunity to perhaps find him earlier. Also, the fact that he was living in a remote area while that generally tended to agree with the profile, I find that kind of surprising. I thought that, like some of the others, that he might be in a semi-rural area in Northern California, not necessarily deep in the mountains of Montana.

MS. FARNSWORTH: And they thought he was younger because, you said because the first bombs were amateurish?

MR. O'BRIEN: That's right. In fact, the first device looked like the work of someone in his late teens when, in fact, Ted Kaczynski at that time was age thirty-six.

MS. FARNSWORTH: And John O'Brien, what happens next? There's a grand jury to be convened on April 17th in Montana. Then what?

MR. O'BRIEN: Well, I think much remains to be seen. We know that there is some strong circumstantial evidence at this point. I think they're obviously looking for some physical evidence. They do have most of the, the remains or the debris of unabomber's bombs over the years on--they've had them at the FBI laboratory in Washington for quite some time, and, uh, I think they're going to try and look for some common characteristics with the debris of those bombs and what was found in the cabin.

MS. FARNSWORTH: And Dave Jackson, the meeting today at the Department of Justice, are they trying to figure out basically where to, to try to prosecute the case?

MR. JACKSON: Yes. I think what's going to happen is that they're going to be led by the evidence, regardless of where they want to charge him for a crime and try him for a crime, they're going to try him where the evidence is strongest, and it's likely they're going to choose one of the states where a death occurred, so that would narrow it down to New Jersey or California. And the most recent bombing was in California. The unabomb task force was headquartered in San Francisco, so the evidence would presumably be freshest in that case, but, again, it'll--it'll determine--it'll be determined by the strongest case they can put together.

MS. FARNSWORTH: Thank you, Dave, and thanks, John O'Brien.

MR. LEHRER: Still to come on the NewsHour tonight, doctor- assisted suicide and coping with the costs of health care. FOCUS - ASSISTED SUICIDE

MR. LEHRER: Now, should doctors be allowed to help patients end their lives? Margaret Warner explores that question.

MS. WARNER: Two recent court decisions have injected new life into an age-old controversy, raising questions of personal freedom, morality, and medical ethics. In the past six weeks, two federal appeals courts, in California and New York, have struck down state laws against doctor-assisted suicides, though they based their decisions on different constitutional grounds. Both states have vowed to appeal the rulings to the U.S. Supreme Court. Our examination of the questions and quandaries raised by these rulings beings with this report from Lee Hochberg of Oregon Public Television.

LEE HOCHBERG: Portland accountant Bill Hancock looks healthy enough, but he knows he's in his last year of life.

BILL HANCOCK, AIDS Patient: Prognosis-wise, I would say 12 months or less for myself--whichever way you go, the outcome is the same, you know, that I'm going to die.

MR. HOCHBERG: Diagnosed HIV positive 11 years ago, Hancock came down with pneumonia and AIDS-related infections last year. He's worked hard and gained back 60 pounds of body weight and muscle. But he knows there's a limit to what his exercycle can do for him.

BILL HANCOCK: You see these people who have no physical or mental abilities and are laying in a bed, you know, racked with pain. And I had big fears about that for myself, I don't want to be that way- -and I'm not going to put my parents through it either. I'm not going to leave them in a position of having to make some kind of decision as to when they're going to pull the plug. I'm not going to do that to them.

MR. HOCHBERG: Hancock says within a year he'll ask his Portland doctor to help him end his life. He's hopeful he can get that help because of a landmark court ruling last month. A Federal Appeals Court overturned a Washington state law that had banned assisted suicide. The justices said the right of a mentally competent, terminally ill person to hasten his own death is a constitutionally-protected personal liberty.

MR. HOCHBERG: [Joanne Scarburry being wheeled to radiation] This first-ever finding of a constitutionally-protected right to die seems to offer a better choice to 64 year old Joanne Scarburry of Portland. Before the ruling, she had tried to get a gun from her son, so she could end her agonizing bout with lung cancer.

JOANNE SCARBURRY, Cancer Patient: Sometimes it gets so bad that you just don't feel you can go on, so it's an option you can take.

MR. HOCHBERG: Are you ready to end your life?

JOANNE SCARBURRY: Well, not right this minute I'm not, but yeah, I could do it.

MR. HOCHBERG: Why?

JOANNE SCARBURRY: Why not? Nothing left.

MR. HOCHBERG: It's a choice Dorothy Hoogstraat's husband never got to make. A professor and a vocal advocate of the right to die, Emerson Hoogstraat died of bone cancer before that right could ever be written into law.

DOROTHY HOOGSTRAAT, Widow: What do you do? You just suffer, I mean, is really what it amounts to. Every rib he had was broken, and you'd go try to move him when he was in bed and he just would cry out because it hurt him so. There was no place you could touch him that it didn't hurt him. And his femur and his right leg was broken. There was nothing, I mean, there was nothing anybody could do for him.

MR. HOCHBERG: But there are many who are fighting vigorously against assisted suicide. The State of Washington plans to appeal the rejection of its suicide ban, to the U.S. Supreme Court.

BOB CASTAGNA, Oregon Catholic Conference: This is as shocking a policy development as can be confronted by the Catholic Church in this nation.

MR. HOCHBERG: And the Catholic Church, calling the court ruling "chilling," is aggressively lobbying judges and state legislatures to reject assisted suicide.

BOB CASTAGNA: What the court has done had been to elevate personal autonomy and the liberty interest of the individual at the expense of the state interest in the preservation of life, prevention of suicide, maintaining the ethical integrity of the medical profession. The potential for abuse of physician assisted suicides, once unleashed in society, is very real.

DOCTOR: [with Bill Hancock] Okay. Just relax for a moment.

MR. HOCHBERG: As advocates and opponents argue, some patients and doctors are taking things into their own hands.

DOCTOR: [with Bill Hancock] Is that tender at all? The liver seems a little enlarged but not dramatic, not real tender.

MR. HOCHBERG: Physicians can be prosecuted for dispensing lethal prescriptions, but a recent Oregon Health Sciences University survey showed 21 percent of Oregon doctors had been asked for lethal prescriptions in the last year. And 7 percent of them wrote such prescriptions. A new study of Washington State doctors reveals similar figures.

DOCTOR: [with Bill Hancock] You continue to astound me in that you're doing so much better than you were six months ago.

MR. HOCHBERG: Bill Hancock's doctor says the new court ruling identifying a right to die will make it easier for him to write Hancock a lethal prescription.

DR. MICHAEL MacVEIGH: I personally would not just be concerned about the legal aspects, any repercussions of assisting a patient with suicide, where previously obviously that would have been a concern.

BILL HANCOCK: It makes me feel better as far as being able to talk to him about it, and it's kind of a relief. You know that there's a potential for that assistance not only from my doctor but also legally.

MR. HOCHBERG: Other doctors say the recent acquittal of so-called "Suicide Doctor" Jack Kevorkian is making it easier for them to respond to their patients' wishes for assisted suicide, as are last month's appeals court ruling that Washington State cannot ban assisted suicide, and the latest ruling that new York State cannot ban assisted suicide. But Dr. Peter Goodwin cautions that until the U.S. Supreme Court upholds the right to die, and state legislators draw up standards to regulate it, many doctors will avoid dealing with it.

DR. PETER GOODWIN, Oregon Right to Die Committee: Oh, there's still a huge barrier because I don't think any physician sort of is secure that, in fact, there has been a law change in his or her state, because there are no safeguards, there are no professional standards established.

MR. HOCHBERG: Goodwin and seven other Oregon doctors wrote Oregon Measure 16, the nation's first law permitting assisted suicide. It requires two physicians determine the patient is terminal, competent, and acting voluntarily in requesting lethal medication. Oregon voters passed it in 1994, but a judge ruled it unconstitutional. That case is also headed for the Court of Appeals.

NURSE: Wow! You're kind of drowsy.

SOCIAL WORKER: On the pain scale zero to ten, where is your pain now?

PATIENT: Zero.

SOCIAL WORKER: Really wonderful!

NURSE: Boy, we did good!

MR. HOCHBERG: As the battle plays out, critics of assisted suicide are pressing hospitals to establish comfort care teams to deal with the special needs of the dying. This team at Portland's Providence Hospital hopes attention to pain relief and spiritual needs will leave patients less inclined to seek suicide.

BOB CASTAGNA: We don't need to resort to killing the terminally ill to solve the problem of pain at the end of life. Between modern means of pain control, hospice care, community involvement in the dying process, we can provide the support that people need as the antidote to asking for the prescription of the lethal overdose.

MR. HOCHBERG: An Oregon Health Sciences University study found doctors have become fare more attentive to end-of-life care after being stunned by the Measure 16 vote.

DR. SUSAN TOLLE, Oregon Health Sciences University: In the media campaign, Oregon patients and families got a lot more sophisticated, they learned that pain is usually treatable, but we don't always do it, and they got more aggressive in saying, give him more, he is suffering, and that made a big difference.

MR. HOCHBERG: Study co-author Susan Tolle says physician referrals to hospices have increased as much as 20 percent and several hospitals have developed comfort care teams. She estimates all but 2 percent of Oregon's dying can now have their discomfort dealt with to their satisfaction.

DR. SUSAN TOLLE: The majority of those who are dying in Oregon will have the kind of care they wanted, and will have a reasonable death, and a much huger number of people are affected by what we're doing in improving comfort care than the number of people who would ever utilize assisted suicide.

MR. HOCHBERG: But Dorothy Hoogstraat doesn't think comfort care would have been the answer for her husband.

DOROTHY HOOGSTRAAT: I don't know what comfort care is. I don't know how you give comfort care to people who have what he had. I mean, perhaps for some things there is comfort care, but for what he had, no, there was not, there was no comfort to it.

MR. HOCHBERG: Bill Hancock says what would make him a little more comfortable in his last two months is a swift legal resolution of his right to die.

BILL HANCOCK: There's no time when you have, when you're looking at 12 months, you don't have a lot of space for a waiting game.

MS. WARNER: Now, two views on the ethical dimensions of doctor- assisted suicide. Margaret Battin is a professor of philosophy at the University of Utah, where she also teaches in the division of medical ethics. Mark Siegler is a practicing physician and director of the Center for Clinical Medical Ethics at the University of Chicago. Welcome both of you. Peggy Battin, you have endorsed these two recent court decisions. Why is that?

MARGARET BATTIN, University of Utah: [Salt Lake City] I think they're to be celebrated as real recognitions of basic civil personal rights. I think we should all sleep a little easier knowing that if we were ever in these circumstances, uh, we could call for this if we ever really needed it.

MS. WARNER: Dr. Siegler, how do you see it?

DR. MARK SIEGLER, University of Chicago: [Chicago] I fear that these decisions are very dangerous for both patients and for our society, Ms. Warner.

MS. WARNER: And what do you mean, dangerous?

DR. SIEGLER: Well, I mean that they set dangerous precedents of permitting or at least weakening the prohibitions against private killing, something that most civilized countries have not tolerated since the Middle Ages. And even though it's done in a medical context, private killing is, is wrong, and very difficult to control, and is subject to many abuses. And I fear that these court decisions have opened the door to permitting assisted suicide and I think also euthanasia.

MS. WARNER: Peggy Battin, how do you respond to those concerns?

MS. BATTIN: Well, in the first place, we're not talking about private killing in the sense that anybody who has a vengeance or some bone to pick with somebody else can simply up and off them. We're talking about a situation in which patients who have reached what they regard as the end of the line can arrange with their physicians under a set of really careful controls to meet death in what they regard as theeasiest, least worst way.

MS. WARNER: Dr. Siegler, what about Petty Battin's main point, that this is a question of sort of personal freedom and, and that, that patients deserve to have this freedom to make this decision themselves?

DR. SIEGLER: It's a powerful point, and, and I'm extremely sympathetic to the rights of people to make their own health care choices. Uh, I merely say that there ought to be limits on, on those rights. There are always limits on most of the things we do in life, and when we're talking about breaking down barriers that have existed in every civilized country, umm, I'm desperately worried. I'm worried for my patients. I've practiced medicine for almost 30 years now, and I'd like to think of myself as being someone who respects my patients' wishes and attends to their needs. And occasionally in my practice, I've cared for dying patients who have at one time or another asked for assistance with suicide. That's often a cry for help. It often indicates that pain management is not adequate, that counseling is not adequate, or sometimes even that the patient is profoundly depressed and needs help in that regard. It, in my practice at least over the 30 years, I've never had a sustained request for a patient who wanted to be assisted with suicide or to be killed. Now, I read about some patients, and I often fear that it's failures of adequate care that they have received along the way, rather than assertions of, of libertarian rights claims.

MS. WARNER: Peggy Battin, do you think Dr. Siegler could be right, that, that really in most cases even patients who think they want to end their lives could have their pain addressed in other ways as we saw in the taped piece and as Dr. Siegler is saying?

MS. BATTIN: Well, I certainly think that we could do a better job of pain control. There is a substantial amount of evidence that we don't do it as well as we could. And I, even a report from Susan Tolle's group suggests that we're improving in our techniques of pain care. Hospice deserves a lot of credit here, however, pain can't always be controlled, and even if it could be controlled, there are some people who are patients who simply don't wish to endure that last downhill course or all of the tail end of it, so that they would prefer to avoid that rather than waiting until they found themselves in which, in a position in which they had very little remaining control over what happened to them.

MS. WARNER: Dr. Siegler, do you--what about that point, that there are patients who just don't want to go through that final several months?

DR. SIEGLER: And I'm deeply sympathetic to them. I want you to note, however, that such people might not always be terminally ill patients for whom the laws seem to apply at this point. I mean, you may have people who fear that they're suffering all the time, or that they've lost their sense of dignity, or they're always unhappy, uh, who may claim the same right that the courts have now accorded to terminally ill people, and that is the right to be assisted with dying. I'm very worried that the class of people will rapidly expand, but even while acknowledging that such people do exist, I don't think that we should take the chance of legalizing assisted suicide and euthanasia that's likely to follow to meet the needs of that small group. They can often find appropriate care from physicians who are sympathetic to their needs. Those physicians, if they assist such patients, have never been subjected in this country to prosecution. Prosecutors have used considerable discretion in acknowledging the rights of patients and doctors to reach certain agreements between themselves. But legalizing this is going to trivialize it. It's going to expand it widely for large numbers of people who may not want this so much, particularly, I'm deeply afraid of the vulnerable populations, the poor, the uninsured, the disabled, the mentally and physically incapacitated, racial and cultural minorities. They're the people who will have most to fear from this policy, not the civil libertarians who have one more right. I'm sorry, but the exit polls on the West Coast demonstrate consistently that the people who are most against assisted suicide tend to be the elderly African Americans, Asians, and women, interestingly enough. Those in favor tend to be young men, people in control of their life, who are successful. I'm worried about the vulnerable populations who will be affected by, by the legalization of assisted suicide.

MS. WARNER: Peggy Battin, speak to that point if you would, this idea that you could move to a slippery slope where you really end up having involuntary euthanasia of people who are the most vulnerable.

MS. BATTIN: Notice what, first what Dr. Siegler is recommending, that there will still be room for private arrangements between physicians and their patients. He said something about, un, physicians who are sympathetic to the needs of their patients, umm. He's worried about legalization, but he seems to make no case about stopping the practice. Now we've just seen data that the practice is occurring. Every study with which I'm familiar shows that there is a substantial practice. Umm, as far as the slippery slope goes, you have to remember that physician-assisted suicide is just one option for meeting the end of one's life. Uh, the other options are, of course, continuing aggressive treatment but also stopping treatment, discontinuing treatment already in progress, or not starting treatment that's in--that could be put in progress, discontinuing nutrition and hydration, either artificial or ordinary, turning to permanent sedation, a policy recommended by some parties to this discussion.

MS. WARNER: And let me just interrupt. Your point is that much of this is legal already?

MS. BATTIN: Much of--all of what I'm discussing now--

MS. WARNER: Is already legal.

MS. BATTIN: --is currently legal and practiced.

MS. WARNER: Dr. Siegler, speak--

MS. BATTIN: Let me add one more.

MS. WARNER: Certainly.

MS. BATTIN: Well--

MS. WARNER: Let me just finish this one point, and then I'll come back to you. Dr. Siegler, speak to that particular point, because this is what the court in New York said, that there are already all these other measures doctors may legally do, such as withdrawing life support, artificial feeding, and hydration, and that there's really no difference between that and then letting--giving the patient drugs to actively end their life.

DR. SIEGLER: And for many years, uh, that distinction between killing and letting die has been a gray line, and the New York court in one step obliterated that gray line and in doing that, I really fear that, that chaos will ensue. It may seem like a subtle distinction, but let me give you one very important implication of obliterating that distinction. The people who are potentially susceptible to having life support withdrawn at any particular moment are only those who require life support to be on board to begin with. They're a relatively small number of people in the population. By contrast, all of us, everybody is potentially at risk if you have a public policy that permits active assistance or active intervention to hasten death, i.e., anybody coming to an emergency room or being at a hospital.

MS. WARNER: So you're saying that there is an important distinction between letting "nature take its course," i.e., taking someone off artificial life support, versus actively intervening to hasten a death?

DR. SIEGLER: I think there's not only philosophical and ethical and clinical distinctions, there's a very important policy distinction in terms of which people are vulnerable or susceptible to the intervention. And the number, the number multiplies rapidly.

MS. WARNER: Peggy Battin, speak to that point, that he's saying there is a difference between the two.

MS. BATTIN: He seems to forget that we're talking about a policy which would, umm, by statute only respect documented voluntarily choices. So the specter of somebody coming into an emergency room and being somehow pushed into, umm, assisted suicide is just simply not reasonable. We're talking about time delays, we're talking about a set of protections, including repeated documentation, uh, that just makes the scenario he's describing, uh, not at all plausible.

DR. SIEGLER: Professor--

MS. BATTIN: As far as the slippery slope goes, the real point is that the argument that Dr. Siegler is making suggests that we are now at the top of the slope and should worry about stepping out onto it. The real truth is that we are already on that slope and the question is can we get ourselves back up to the top? The practices I was starting to enumerate include also the over-use of opiates, umm, opiate sedation, in a way that is legally permitted and also incidentally permitted under the teachings of the Catholic Church, provided it is done in a way that is intended to treat pain, though it is foreseen, though not intended that it will cause death. Well, if you think it is a safe practice to excuse your physician from causing your death because that physician gave you pain medication which would kill you by depressing respiration, although he or she claims that he didn't intend to cause your death, that's not a safe situation. That's a situation in which all the groups which Dr. Siegler enumerates are at far greater risk than if the practice of assisted suicide is made legal, is brought out into the open, is practiced only under careful--careful restrictions. So I think--

MS. WARNER: All right, let me--

MS. BATTIN: --the case for preventing abuse is much stronger with legalization than without it.

MS. WARNER: Dr. Siegler, address that point, i.e. that you, yourself, acknowledge this already goes on and what Peggy Battin is saying is in a way that's not only hypocritical or potentially more dangerous than having it out in the open and having guidelines and so on.

DR. SIEGLER: I think the practice may go on at an extraordinarily low level. I think legalizing it is going to generalize it to large numbers of people in the population. It's going to expand it in ways that we'll not be able to control. It will be subjected to far more abuses than currently exist. I'm not happy with the way it's going on right now. I mean, if it were left to me, I would say that while doctors and patients might agree between themselves that the doctor will supply the patient with enough medication perhaps for the patient to kill himself or herself, it ought to be regulated first by being looked at in advance by a committee of professionals and lay people and even perhaps getting some prior judicial review, and secondly, it ought to be looked at retrospectively in a public arena so that these actions are not done in private.

MS. WARNER: Dr. Siegler, thank you so much, and Peggy Battin. I'm afraid we'll have to leave it there.

DR. SIEGLER: Thank you.

MS. WARNER: Thank you. SERIES - CHANGING TIMES

MR. LEHRER: Finally tonight, the changing world of health care in America. This week we will be looking at various efforts to control the skyrocketing costs of health care and the impact they're having on providers and patients alike. Part one, an experimental Medicaid program in Tennessee. Fred De Sam Lazaro of KCTCA, Minneapolis-St. Paul reports.

FRED DE LAZARO: For about the past two years, Christina Christy and her mother, Deborah, like all Medicaid recipients in Tennessee, have gotten their health care coverage through a private HMO, or Health Maintenance Organization.

DOCTOR: [examining little girl] Let's have a look at the ring worm.

MR. LAZARO: The State of Tennessee, which used to pay providers directly in a traditional fee-for-service arrangement, now pays a fixed premium to HMO companies. David Manning was the architect of the switch to an all-managed care system.

DAVID MANNING, Former Commissioner of Finance: We made a very conscious decision that it was time for government to do what large employers and large purchasers of health care were doing all over the country. And, in effect, you must be willing to use all of your leverage in the marketplace.

MR. LAZARO: Manning was convinced the state could cut its Medicaid costs by a third with a more efficient system of delivering health care. Accordingly, he steeply discounted prices the state would be willing to pay under the new system.

ANNOUNCER: [commercial] In Tennessee, the sky is a little bluer.

MR. LAZARO: Blue Cross/Blue Shield, the state's largest insurer, bid to be part of the new system, unable to ignore a big customer. Blue Cross had provided coverage for the state's public employees.

ANNOUNCER: [commercial] Under the state's new TennCare health insurance program you can join them.

MR. LAZARO: Other new managed care companies like Omnicare also went after a share of the 700,000 Medicaid clients. The competition yielded extra coverage in some cases for people like Deborah Christy.

DEBORAH CHRISTY: Well, this pays for a lot more of the kids'-- the children's medicines that Medicaid did not.

MR. LAZARO: Competition also meant the state had to pay less. In fact, enough money was saved to add coverage for 400,000 non- Medicaid clients like Elizabeth Adams and daughter Stephanie.

ELIZABETH ADAMS: She is an asthmatic, and for a few years there, she was really bad, and if it hadn't been for TennCare, I might have lost her a couple of times because I couldn't afford the medicine on my own.

MR. LAZARO: Many of these working poor have their premiums subsidized. Those previously uninsurable because of preexisting conditions also are included in the expanded program. Legal Aid Attorney Gordon Bonnyman thinks the expansion of the program will make it better for everyone.

GORDON BONNYMAN, Lawyer: When you segregate the poor in a program for the poor, it is a poor program and one of the most exciting things, I think, ethically and from a health policy standpoint about TennCare is that we have a way of making sure that a system that is serving primarily poor people also feels accountability to meet the standards that are demanded by people who pay premiums and expect things to work well.

MR. LAZARO: But TennCare has met with fierce resistance from doctors, who say the cost savings have come at considerable expense to them. Nashville internist Winston Griner says the fixed reimbursement paid by TennCare HMO's is unfairly low for a population especially costly to care for.

DR. WINSTON GRINER, Internist: The indigent, the poor, are sicker. They consume more responsibility of my time and my colleagues' times, the hospital systems' times, the home health agencies' times, the pharmaceutical support, the devices to support their needs and maintain and restore health. Those patients are making up 45 to 50 percent of our patient visits, but they're only 17 percent of our, of our revenues.

MR. LAZARO: Doctors' reluctance to participate often meant a shortage of specialists in some areas but TennCare's new director, Rusty Siebert, insists the fees paid now are competitive, and he says the medical community's initial resistance is being overcome.

RUSTY SIEBERT, TennCare Director: When TennCare was first implemented, there was less than 6 percent managed care penetration in the state of Tennessee, so it was a new ammo. The program, itself, is burning in. Physicians are, I think, much more accustomed now to a managed care approach than they were previously. And as a result of that, customer satisfaction has been way up.

MR. LAZARO: But for some doctors and medical institutions, the new system has caused major disruptions. One of the biggest casualties is Memphis's regional medical center known locally as the Med in one of the poorest corners of Tennessee.

DR. SHELDON KORONES, Neonatologist: We used to have about 100 babies here pretty regularly. Now we have about sixty to seventy.

MR. LAZARO: Dr. Sheldon Korones, a pioneering neonatologist, left a lucrative private practice 25 years ago to build this intensive care unit. Most babies here are born very prematurely to poor and young mothers, often with drug-related complications.

DR. SHELDON KORONES: [speaking to nurse] So he's improved, right?

MR. LAZARO: The Med has had to fire 700 workers, almost a third of its staff, because it has lost Medicaid patients, people now required to go to other hospitals under contract to their HMO's. At the same time, the Med remains the so-called "safety net" hospital, saddled with an expensive patient-load, including people still uninsured.

SPOKESPERSON: [talking to young women] So it's important to know what's normal for a pregnancy and to know what to expect as you go along in the pregnancy until you have the baby.

MR. LAZARO: The Med has aggressively tried to heal itself. It has launched or stepped up several programs in prevention, trying to stave off expensive complications by providing prenatal care and advice to pregnant teenagers, for example.

SPOKESPERSON: [talking to young women] Breastfeeding is best for the baby because it provides the baby with those nutrients.

MR. LAZARO: To better compete in the marketplace, the Med has also formed its own Medicaid HMO, using its affiliation with the University of Tennessee Medical Center to open a network of clinics across Memphis. Nobody doubts the Med will survive, but some are worried for its patients. Sharmal Jones is 16 months old and weighs 15 pounds, far from normal, but a far cry from his birth weight of one pound.

ELLEN BROWN: I'm so proud of him.

MR. LAZARO: Sharmal was discharged by Dr. Korones four months after he was born, stable, but with a surgically-implanted shunt to drain excess fluid that was accumulating in his brain. However, complications developed that apparently went unnoticed or untreated for months by the primary care doctor assigned to Sharmal under TennCare, resulting in emergency surgery and the child's development was slowed further says his mother.

ELLEN BROWN: We saw my first primary doctor three times. If he had really checked it out and then sent me where I needed to go, that neuro doctor would have, he would have found that, you know, something was wrong, instead of me sitting there, you know, not knowing what I'm doing and find out that if I hadn't a been there in so many minutes, my baby would have died.

DR. SHELDON KORONES: Here's a baby that's got a shunt. He's got to be seen by a neurosurgeon and followed, obviously, to everybody, uh, but no, that wasn't the case. She couldn't get to one, and perhaps her adeptness at manipulation isn't as great as some other people but as a result, this baby was an emergency. That would not have happened two, three years ago.

MR. LAZARO: Supporters of TennCare say there were just as many allegations of shoddy care under the old system. If the financial incentive under TennCare is to do less for patients, they say the incentive in the old system was to over-treat, harmful and unsustainably expensive.

DAVID MANNING: Every state is going to face that situation in the future. The federal government faces that, no matter how the debate in Washington turns out today. International economics are not going to allow us to continue to infuse huge sums of new money into a health care system that's already spending two to three times what the rest of the world with whom we're competing is spending.

MR. LAZARO: Under TennCare, costs have risen at a relatively low 5 percent annually, but many analysts say the key question is whether and for how long this low inflation can be sustained. RECAP

MR. LEHRER: Again, the major stories of this Monday, federal prosecutors met in Washington with Justice Department officials on how to proceed in the unabomber case. Ethnic fighting erupted in the African nation of Liberia. A State Department spokesman said 10,000 people had taken refuge at U.S. embassy sites in the capital of Monrovia. And a White House spokesman said the United States does not foresee fighting breaking out in the demilitarized zone between North and South Korea. We'll see you tomorrow night with part two of our health care series, among other things. I'm Jim Lehrer. Thank you and good night.