I have not heard a single person claim, during debates about Question 2, that the quality of end-of-life care in Massachusetts is acceptable. There is clearly overwhelming agreement that significant improvements are needed. The questions are:
What improvements are most urgent? How can we achieve them?
Tomorrow, millions of Massachusetts voters will be asked to vote on a different question, Question 2:
Should it be legal for "a physician licensed in Massachusetts to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that person's life"?
Question 2 misses the point. It uses the wrong process. It is premature.
Most importantly, there is a better way.
So I will vote NO.
1. Misses the point
Despite our current major shortcomings in end-of-life care, Massachusetts can and should lead the nation in this area. We can and should be guaranteeing what might better be called a "right to care" than a "right to die" -- i.e. a right to care that is compassionate, including symptoms adequately controlled at all times; that ensures dignity, as defined by the patient; and that respects autonomy, i.e. is always based in an understanding of and respect for the patient's wishes.
As a recent Boston Globe editorial explains in detail, Question 2 will do little or nothing to achieve that.
2. Wrong Process
We should not be using a ballot initiative to decide how best to provide health care for people.
A ballot initiative is a poor process for deciding what to do when both issues and possible solutions are complex. Almost everyone who has approached me in recent weeks about Question 2 has been uncertain -- some have been quite wrong -- about exactly what it would do (or not do). No matter what decision is made tomorrow, I will have no confidence that that decision represents the well-informed judgment of the majority of voters.
There were, and are, better approaches. For example, if the law proposed in Question 2 were going through a legislative process, we would have many possibilities for engaging the people of the Commonwealth in public deliberation. This process would likely be far more constructive than much of what we have seen in recent weeks, too often dominated by fear tactics than by facts and reason. Perhaps most importantly, in that public deliberation we would not be forced into the unfortunate yes/no choice we have tomorrow about a proposal that even many supporters agree is imperfect. In a legislative process, each part of a proposed law can be independently scrutinized. Any part that needs improvement or amendment can be changed. And entirely new solutions sometimes emerge.
Even proponents of Question 2 agree that the choice of "assisted suicide" should be a "palliative care option of last resort" -- i.e. an option to be considered "when unacceptable suffering persists for terminally ill patients despite state-of-the-art palliative care."
A moral precondition of promoting a "last resort" option is that reliable access exists to the other options. Too many people in Massachusetts today do not have reliable access to "state-of-the-art palliative care" -- including to effective pain and symptom management, or to the support services they need in order to be able to die peacefully at home, if they prefer.
Passing Question 2 tomorrow will make it possible that some dying patients who want to be at home for their last hours and days will reasonably decide that their best available choice is assisted suicide, even though they might have preferred other options, such as more adequate home-based palliative care services.
The time to consider adding "assisted suicide" to the list of a patient's options will be when we have first guaranteed universal access to "state-of-the-art palliative care".
4. A Better Way
No matter what the outcome is on Question 2 on Tuesday, starting on Wednesday we should all unite to do whatever it takes to ensure that every dying patient in Massachusetts has reliable access to state-of-the-art palliative care, so that every dying patient can be cared for the way s/he would have wanted. One possible starting point is the recommendations of the Massachusetts Expert Panel on End-of-Life Care: The Urgency of Health System Reforms to Ensure Respect for Patients' Wishes and Accountability for Excellence In Care.
Few of the recommendations in that report, submitted to Governor Patrick more than two years ago, have yet been implemented. On Wednesday we should begin. I will suggest some specific ways we can start in my next posting.
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