Of all public controversies in recent years, assisted suicide is perhaps the one that is surrounded by the greatest degree of misunderstanding. For example, one often hears it referred to as the "right to die." Yet assisted suicide has nothing to do with letting someone die. Neither the law nor medical ethics requires that a person be kept alive by being subjected to unwanted medical treatment.

Furthermore, the debate isn't about the tragic personal act of suicide. Nor is it about attempted suicide. Neither suicide nor attempted suicide is considered a criminal act.

Instead, the current debate is over whether public policy should be changed in a way that will transform prescriptions for poison into "medical treatment."

Oregon is the only place in the world with a specific law permitting assisted suicide. (Although widely practiced in the Netherlands, euthanasia and assisted suicide remain technically illegal there.) Unfortunately there is no way to know of abuses, or even the number of deaths, occurring under the Oregon law since failure to adhere to its reporting requirements is not penalized.

But we do know that, in Oregon, a doctor can write a prescription for drugs that are intended to kill the patient. When the prescription is filled, the pharmacist doesn't give the usual instructions about how to safely take it. Instead, a patient is more likely to hear, "Be sure to take all of these pills at one time -- with a light snack or alcohol -- to induce death." Directions center around making certain that the patient dies after taking the prescription.

The lethal drugs are covered by some Oregon health insurance plans. They are paid for by the state Medicaid program under a funding category called "comfort care." (This certainly gives meaning to the statement, "All social engineering is preceded by verbal engineering.")

Even though Oregon stands alone in approving such "comfort care," there is a full court press to expand its legalization to every state. Already Hawaii's governor has vowed to propose legalization of both euthanasia and assisted suicide. A court challenge to Alaska's law prohibiting assisted suicide has been filed. Attempts to place the issue on the ballot have begun in several states. And, in virtually every state, there is a lawmaker who is drafting an assisted suicide proposal.

Assisted suicide activists expect many of these efforts to fail initially but count on their providing the opportunity for publicity. This publicity follows a rarely altered pattern.

First, a "hard case" is spotlighted. This is accompanied by the assertion that assisted suicide was a necessary last resort. Assurances are made that the method and timing of death were freely chosen by the person (who is, conveniently, dead and thus unable to refute these claims). Finally, accusations are made that anyone who dares raise questions about such a demise lacks compassion and merely wants to force others to suffer.

It should be noted that many advocates of assisted suicide seriously believe that what they're proposing is a compassionate choice that should be available. However, despite their sincerity and good intent, it is the content, not the intent, of the policies and laws they espouse that will ultimately affect each and every person.

Whether other states embrace Oregon-style "comfort care" will depend upon a willingness to carefully examine what is truly at stake in this debate. This is, above all, a debate over public policy.

No matter what one's views may be about the concept of assisted suicide, it's necessary to reflect on the context in which it would be carried out. This reflection necessarily includes consideration of contemporary economic forces affecting health care.

As acting solicitor general Walter Dellinger said during his 1997 argument against assisted suicide before the U.S. Supreme Court, "The least costly treatment for any illness is lethal medication."

He was, of course, correct. A prescription for a deadly overdose runs about $35. Once taken, the patient won't consume any more health care dollars.

Cost containment could well become the engine that pulls the legislative train along the track to death on demand. Those who advocate dismantling the barriers that now protect patients from assisted suicide recognize the power of cost containment. For example, Hemlock Society co-founder Derek Humphry recently explained his belief that, in the final analysis, economics will drive assisted suicide to the plateau of acceptable practice.

There's no question that economic considerations have always played a role in decisions about health care.

Most of us can recall a time not long ago when patients were routinely subjected to unneeded tests and treatments. And we know now that money fueled these abuses. Then, health providers were reimbursed for everything they did to or for a patient.

Fortunately, patients and families became more aware of their rights to reject unwanted and unnecessary interventions. But the end to overtreatment didn't stem primarily from a respect for patients' rights. Instead, it grew out of changes in the way health care is reimbursed.

No longer do doctors and hospitals get paid for all they do. Instead their incomes often depend upon how little they provide. And now, not surprisingly, the pendulum has swung to the other extreme where more and more people (insured and uninsured alike) find it difficult, if not impossible, to get needed and wanted health care. Again, the fuel for change is money. The catalyst has been managed care.

Managed care has dominated health care delivery is recent years. A significant number of health maintenance organizations (HMOs) are "for-profit" enterprises where stockholder benefit, not patient well-being, is the bottom line. Gatekeepers operate to protect resources by delaying or denying authorization for services.

Some programs have what are called "gag rules" which prohibit doctors from telling patients the whole truth about interventions that might be helpful. The stark words, "There's nothing that can be done" may really mean, "There's nothing more we'll pay for." But patients may not know that.

Imagine the patient who is in pain and is given the "nothing can be done" routine. Pain control is definitely given short shrift by many health plans. Some plans don't provide coverage for chronic pain except in very limited circumstances. Others put an unreasonably low cap on the amount paid for hospice care. (One Oregon insurer limits payment for hospice care to a $1000 maximum.)

Navigating the murky health insurance waters -- of services not covered, services not approved and the complex methods of co-payments -- is particularly difficult for patients who are seriously ill and/or in pain. They have precious little energy to deal with a system that seems impenetrable.

Few people pay much attention to the particulars of their health insurance coverage until they are ill. By then it may be too late.

Assisted suicide advocates assure us that a physician would only prescribe the lethal overdose after careful discussion with the patient.

To make this assertion represents the height of naiveté, if not disingenuousness. It's a presumption made by those relatively few people who have the luxury of a personal family physician who may also be a golfing or bridge partner. Having a physician friend who would talk over a planned assisted suicide before prescribing a lethal dose is nothing more than a fantasy for the vast majority of Americans.

Today most people are fortunate if they see the same doctor from visit to visit and, even when they do, time constraints exist.

For example, some managed care programs expect physicians to limit new patient visits to 20 minutes and are told to devote no more than 10 minutes to a returning patient.

Do we really believe that health plans that now limit doctors' time in this manner would let doctors spend hours discussing the pros and cons of assisted suicide before prescribing the fatal overdose?

Conflicts of interest also should be recognized. An obvious concern is the possibility that a physician could persuasively "offer" the option of assisted suicide to a patient whom the physician knows may pose the threat of a malpractice case. But there are more subtle, more likely, types of competing interests between physicians and patients.

For instance, some health programs provide financial bonuses to doctors who conserve economic resources by withholding time or care from patients. It's reasonable to point out that this has the potential for conflict of interest between patients and physicians.

Add to this the results of a survey published in 1998 in the Archives of Internal Medicine. It found that doctors who are the most "thrifty" when it comes to medical expenses would be six times more likely than their counterparts to provide a lethal prescription. These same doctors would be diagnosing, screening and counseling patients -- and prescribing lethal drugs for assisted suicide.

Even in light of such concerns, activists favoring assisted suicide contend that the choice of assisted suicide should be available.

Choice is meaningless, however, if there is only one affordable option. True, advocates of assisted suicide insist that every person , prior to receiving assisted suicide, would be offered all options. This appears protective. But there is a vast difference between an offer of something and the ability to accept that offer.

This difference was acknowledged at a conference where assisted suicide guidelines, drafted by a San Francisco ethics committee, were under discussion. The guidelines stated that physicians had to offer palliative care (pain and symptom management) to patients before providing assisted suicide. However, when asked if there was also a mandate that patients have actual access to this care before being given a lethal prescription, the ethics committee spokesperson replied that there was no such requirement.

Thus the offer of all options is grossly misleading. It creates the illusion that all options would be available to people when, in fact, they would not. In theory, offering the choices between unaffordable palliative care and an affordable drug overdose is one thing. In practice, it takes little imagination to figure out which "choice" is really available.

As attorney and consumer advocate Wesley Smith has said, "The last people to receive medical care will be the first to receive assisted suicide."

If we embrace assisted suicide as medical treatment, it will return our embrace -- with a death grip that is cold, cruel and anything but compassionate.

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Rita L. Marker is an attorney and executive director of the International Task Force on Euthanasia and Assisted Suicide. She is the author of Deadly Compassion (William Morrow and Co., 1993).

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This article first appeared in Insight magazine (March 8, 1999).