Death with Dignity?

Illustration by Shout

After a fall at his Florida retirement home, Lester Angell was robbed of any mobility not already lost to metastatic prostate cancer. An impending hospital admission promised to steal what little autonomy the 81-year-old had left. As the last act of an independent but terminally ill man, Angell took control of the time and circumstances of his death by reaching into his nightstand and pulling out a pistol.

“No one should have to die alone that way,” says his daughter, Dr. Marcia Angell, a senior lecturer in social medicine at Harvard Medical School. Fourteen years after she wrote about his death in the New England Journal of Medicine, Angell is certain her father would have lived longer and met a more peaceful end if, rather than a gun, he’d had a prescription on his nightstand. “It was wrong that medicine abandoned him then, and it’s wrong now,” she says.

Today Angell is helping lead the drive to place physician-assisted suicide on the Massachusetts ballot next November. Hundreds of volunteers are buttonholing voters outside grocery stores across the state, collecting the 70,000 signatures necessary to put the measure on the 2012 ballot. If the initiative passes, we’ll join Oregon and Washington as the only states that allow physician-assisted suicide.

Getting there will not be easy: America is evenly split between supporters and opponents of physician-assisted suicide, according to a 2005 poll conducted by the Pew Research Center for the People & the Press. So the side that prevails next November will be the one that succeeds in framing the debate: Is physician-assisted suicide a patient’s right to choose “death with dignity”? Or, as Cardinal Sean O’Malley contends, is it a despicable act of “sheer brutality”?

Before we get into the debate, let’s look at what’s proposed in Massachusetts: At the end of his or her life, a mentally competent adult would request a prescription for a fatal dose of medication, usually barbiturates. Two doctors would have to certify that the patient is within six months of death, and is making the request voluntarily. The patient would be required to ask two separate times, at least 15 days apart; one request would need to be in writing and witnessed by two people. Before any prescription could be written, the doctor would then have to wait 48 hours after receiving the second request, and would also have to inform the patient about alternative courses of action, including pain management and hospice care. Physicians would be prohibited from administering the lethal dose themselves, and no doctor who objected to the law would be required to write such a prescription.

It’s a measured proposal loaded with safeguards, and it reflects the wisdom and experience of a diverse group of experts: Angell and her 14 co-petitioners, including a rabbi who served for 24 years as a chaplain and director of pastoral care at Beth Israel Deaconess Medical Center; two professors of medical ethics at Harvard; a psychiatrist from Tufts; a professor emeritus of law and bioethics at Boston College; and the executive director of the state’s American Civil Liberties Union chapter.

The professionalism of the advocates and the proposed checks and balances should, but won’t, derail the fear-mongering by those who insist that such a law would open the door to the involuntary killing of the weak, the disabled, the elderly, or those whose care has become a financial burden for their families or the state. “By rescinding the legal protection for the lives of a category of people, the government sends a message that some persons are better off dead,” Cardinal O’Malley told the lawyers and judges who this fall attended the annual Red Mass for members of the legal profession. “Those who choose to live may be viewed as selfish or irrational, as a needless burden on others, and might even be encouraged to see themselves in that way.”

Conflating euthanasia (in which another decides that it’s time for you to go) with the decision to accelerate one’s own imminent death is an effective bit of rhetorical sleight of hand. The Catholic Church has as much right as any tax-exempt institution to weigh in on this issue, but it does not have a right to pollute the discussion with intentionally misleading arguments. Unsurprisingly, paternalism is at the heart of the Church’s opposition to this measure. The cardinal does not trust his flock to act in its own best interest, temporal or spiritual. Promoting the Catholic dogma that suffering is an ennobling, even redemptive experience is the stuff of sermons, and imposing it on those who do not share that belief comes close to breaching the line between church and state.

Curiously, the Roman Catholic Bishops of Massachusetts draw a distinction between physicians writing lethal prescriptions for patients and withdrawing their life-sustaining treatment. This September, they released a statement arguing “extraordinary means that may not alleviate the underlying condition and may excessively burden the patient are not obligatory.” In other words: If you’re going to die, your family and doctors are released from a moral obligation to attempt “extraordinary” medical care. So it’s morally defensible for a daughter to authorize doctors to unplug the respirator that is keeping her comatose mother alive, but morally indefensible for a mentally competent patient to choose to hasten his own imminent death?

O’Malley may have drawn his own line in the sand, but there are signs that other quarters that were once unequivocally opposed to physician-assisted suicide are reconsidering their position. The Massachusetts Medical Society, which publishes the New England Journal of Medicine and represents the state’s 23,000 doctors and medical students, made it clear 14 years ago that it did not agree with the editorial Angell wrote endorsing physician-assisted suicide. This fall, though, the group’s ethics committee began meeting to reassess the organization’s stance, and is expected to make its recommendation at the society’s interim meeting this month.

The committee would do well to look at the data. In the 13 years since the law took effect in Oregon, 525 patients have died from swallowing prescribed lethal drugs, according to that state’s Public Health Division. Contrary to predictions by critics that the poor and the uninsured would be pressured disproportionately to end their lives early, in Oregon most who chose the option have been white, male, and well educated. Of the 96 prescriptions written by 59 physicians last year, 65 were used—meaning one-third of the patients who got a lethal prescription chose not to use it. The comfort was in knowing it was there if they needed it. The median age of those who did swallow the pills was 72. Almost 97 percent died at home; 93 percent were receiving hospice care at the time of their death. More than 96 percent had health insurance, 60 percent of it privately funded rather than provided by Medicare or Medicaid.

The most frequent reason for asking for the prescription in Oregon last year, mentioned by 93.8 percent of the patients, was the loss of autonomy that often accompanies the last stage of a fatal illness. They were not choosing death over life—the cancer or heart disease or respiratory failure had done that for them—they were exercising control over their final days on earth.

“This is not a dance between life and death,” says Angell. “The patient is going to die. It’s a choice about the kind of death that patient is going to have and who gets to decide. The doctor? The state? The church? The patient? What possible purpose is served by telling someone he cannot release himself from his suffering? Who is anyone to tell an individual what degree of suffering he can endure? What is Cardinal O’Malley protecting them from? Themselves?”