[Author's note: apologies for the inconsistencies in the size of the fonts in this posting. I have not yet mastered all the technical details of the blog's software.]
The issues Question 2 raises are truly profound and deeply important -- including about life and what gives it meaning; about death and what "dignity" entails; about the roles, responsibilities, and possible limitations of doctors in alleviating human suffering; and about the boundaries of government regulation in our private lives.
At the end of this posting, I will suggest some ways to learn more about these issues. But first, as I promised in yesterday's posting, here are three reasons why I do not think you need to be afraid about what will happen on November 6 with Question 2, whether or not it passes.
1. Based on Oregon's experience, the odds are roughly 99.8% that Question 2 will not change the care you or your loved ones receive.
In Oregon, physician-assisted suicide has been legal for 14 years. Since then, of every 1,000 people who die, only 2 request and then receive a prescription they can use to end their lives. Of these 2, almost a third never take the prescription. So for more than 998 of 1,000 people who die in Oregon, the care they choose, and the care they then actually receive, is a matter of the availability and quality of the existing mainstream options. In Oregon these are already good, and continually improving.
If Question 2 passes and the Oregon experience holds true here in Massachusetts today, we can expect that for 99.8% of us our care at the end of life will involve the same choices that exist today. These range from "try to keep me alive as long as possible no matter what" to "just keep me comfortable and at home", or anything in between, or any combination or sequence of "life-prolonging" or "comfort/home" options.
For me, this means that if what you care about is ensuring that people in the Commonwealth have more reliable access to the care they want and need at the end of life, Question 2 is at best a 0.2% solution.
In Massachusetts, far, far too many of the other 99.8% do not today have reliable access to the palliative care and hospice services they need. I personally am far more worried about what will (or won't) be done for them, than I am about what we decide to legalize (or not) for the 0.2%.
2. If a patient is concerned about physical suffering, in almost all cases there are ways besides "assisted suicide" to ensure that that suffering can be controlled.
If comfort ever becomes a patient's overriding goal, then it can almost always be adequately achieved. If necessary (it usually is not), this can mean use of sedating medications so that the patient is no longer conscious. In addition, if it is clear that a patient wants no further life-prolonging measures, then there is a strong moral consensus in the medical profession that there is no obligation to continue medically-administered nutrition or hydration. In the case of Nancy Cruzan (1990), the U.S. Supreme Court affirmed a "constitutionally protected right to refuse lifesaving hydration and nutrition." With zero hydration, a human being does not live more than two weeks. It is true that "up to two weeks" can feel like a very, very long time. But turning instead to "assisted suicide" if that becomes legalized could take even longer: under the procedures stipulated in Question 2 the minimum time from a patient's initial request to a prescription being written is 15 days.
Some people conclude from this that if everyone in Massachusetts had prompt, reliable access to superb palliative care and hospice services -- which is tragically not even remotely the case today -- there would be no reason or need for Question 2.
3. If Question 2 passes, there are multiple ways to ensure adequate safeguards to prevent "abuse".
The result of this ballot initiative will not -- or at least should not -- be the end of the story. Some opponents of Question 2 point out what they consider major shortcomings in its stipulated safeguards. Even if these opponents are right, then just as is true for any area of medical practice, there are ways those can be fixed.
First, if changes in the law are needed, our state legislature can make those changes. Whether or not they will actually do so is obviously another matter, but that will be up to us.
Much more importantly, all that passing Question 2 will do is establish the minimum conditions under which it will be legally permissible for a physician to write a lethal prescription. The "standards of care" to which physicians are held accountable, including medicolegally, are often higher than the minimal standards establishing what a physician's licence permits her or him to do.
For example, as a licensed physician in Massachusetts, I am permitted under Massachusetts law to do many things that my hospital, Beth Israel Deaconess Medical Center, does not allow me to do, and that my malpractice insurance would not cover if I did them. I am not allowed by BIDMC to prescribe complex chemotherapy. I am not even allowed to do many basic medical procedures, such as a "thoracentesis", which involves inserting a needle into a patient's chest to drain fluid for diagnostic or therapeutic purposes. I did those routinely during my residency training, and I think I was actually quite good at them. But I have not done one for over 25 years. As a licensed physician, I am permitted by Massachusetts law to do them, but not as a BIDMC physician.
If Question 2 passes, then at Beth Israel Deaconess Medical Center, where I practice, we will create a policy with guidelines and procedures that all of our physicians will be expected to follow. If any physician does not follow those, s/he will be risking serious trouble, including possible loss of privileges at BIDMC. I expect that BIDMC's guidelines will include things not specified in the Question 2 law. For example, Question 2 does not require that a patient receive counseling from a physician or nurse with training in palliative care to ensure that the patient is fully informed of the full range of options for preventing and alleviating their suffering. I believe that we at BIDMC will require something like that.
If Question 2 passes, I expect that most if not all health care facilities and physician practices in Massachusetts will, like BIDMC, adopt guidelines or policies that provide excellent protection for all of our patients.
If these thoughts leave you still worried about the impact of passing Question 2 on vulnerable people, then by all means vote "No" on November 6.
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For further reading:
Below are a few sources of additional information that I hope will help you understand the issues raised by Question 2. Read as much or as little as you feel you need to cast a thoughtful vote on November 6.
Some people deeply committed to respect for "patient autonomy", and to ensuring that a patient's suffering is always effectively addressed, will nonetheless vote No on Question 2. To understand why, I suggest you read a cautionary historical perspective by Dr. Ezekiel J. Emanuel that was published in The Atlantic in 1997. It covers many historical, moral, political, and practical aspects of the "assisted suicide" and "euthanasia" debates. If your time is limited, you can read a shorter op-ed by Zeke in yesterday's NY Times that highlights some of the key points he made in the earlier article, which remain relevant today.
For a very different perspective, and to understand why some people with a deep reverence for human life, up through its very end, will vote Yes on Question 2, I recommend learning from one of the physicians whose moral values, commitment to his patients, and contributions to responsible public debate I most admire, Dr. Timothy Quill. Tim is a deeply thoughtful, longtime proponent of legalizing physician-assisted suicide. Tim wrote a courageous article in 1991 in The New England Journal of Medicine, which sparked widespread national debate at the time (and since), about how he, in violation of NY state law, wrote a prescription for a 45-year old patient of his with leukemia that she used to end her life on her own terms, peacefully and at home. An article he wrote in 2008 titled "Physician-Assisted Death in the United States: Are the Existing 'Last Resorts' Enough?" is a good starting point for understanding why he would almost certainly vote Yes on Question 2.
A user-friendly summary of ballot Question 2, including listings of the main arguments made by both proponents and opponents, together with links to additional information, is provided by the wonderful collaborative on-line resource "BallotPedia".
Additional perspectives from a group of primarily lay people in Massachusetts, including some very thoughtful "white papers" they have written that are directly relevant to Question 2, can be found on the website "Medical Ethics and Me", provided as a public service by a Community Ethics Committee affiliated with the Harvard teaching hospitals. We need more voices like theirs to be actively involved in shaping every aspect of our health care system. That means your voice, too.
A Final Note on Civility in this Debate, and a Hope for November 7 and Beyond:
Zeke Emanuel (see above) is a longtime colleague and friend. I was horrified and saddened in 2009 when Zeke himself was one of the victims of the campaign of Orwellian lies about non-existent "death panels" during the national health care reform debates. Read his 1997 article in The Atlantic, or his op-ed yesterday, both eloquently expressing his opposition to physician involvement in assisted suicide or euthanasia. Then read the "Death Panels" section of the Wikipedia entry on Zeke, describing the utterly dishonest attacks against him as President Obama's "Doctor Death." From these I think you will learn, as I did, a lot about the challenges of engaging in thoughtful public discussion about difficult issues in our country today. As a nation we should be embarrassed and ashamed about the state of public discourse that we are tolerating.
We need to do better, and we can. I hope that starting November 7 in Massachusetts we will leave the polarizations, fear tactics, and at times self-righteous moralizing of the Question 2 debates behind us. I hope that starting November 7 we will unite in working together to improve end-of-life care for everyone in the Commonwealth. And I hope that the way that we do so will set an example of civil public discourse, and of the rapid progress in health system improvement that such discourse can make possible, that is worthy of being emulated elsewhere, and one day nationally.
The author is solely responsible for the content.