Mass. Voters To Weigh In On ‘Death With Dignity’ Act

John Kelly, disabilities rights activist and founder of Second Thoughts, and Dr. Marcia Angell, a senior lecturer at Harvard Medical School and former editor of the New England Journal of Medicine. (Jesse Costa/WBUR)

John Kelly, disabilities rights activist and founder of Second Thoughts, and Dr. Marcia Angell, a senior lecturer at Harvard Medical School and former editor of the New England Journal of Medicine. (Jesse Costa/WBUR)

BOSTON — This November, Massachusetts voters will decide whether the state should allow physician-assisted suicide for some terminally-ill patients.

For a closer look, WBUR’s Bob Oakes spoke with people on both sides. John Kelly, a disabilities activist and founder of the group Second Thoughts, opposes the ballot question. Dr. Marcia Angell, a senior lecturer at Harvard Medical School and former editor of the New England Journal of Medicine, supports it.

Dr. Marcia Angell: It’s a compassionate law. It’s also a law that respects the autonomy of dying patients. I can’t see why anyone, any organization, any individual would possibly presume to tell someone else how much suffering they have to endure as they face death.

Bob Oakes: John Kelly has a different point of view. John, why do you want this question to fail?

John Kelly: We’re talking about a social policy here, not just individual choices in a fairy tale land where everyone’s affluent and has had full control over their lives their entire life, but people who are vulnerable, people with psychiatric illness, people who depend on care for family members who may not have their best interests at heart.

Dr. Marcia Angell: The best answer is the experience in Oregon, which has had the same law for now almost 15 years. And what they have found is that the people who use this law are not vulnerable people — except that they have terminal illness, of course — but that they tend to be more affluent, better educated, well insured and fully informed.

Bob Oakes: There’s a lot of concern by families and patients at the end of life around the “when” question — when is the patient expected to die and how and whether a doctor really really knows when a patient’s time is up so that that person might consider ending his or her life.

Dr. Marcia Angell: Here again the best evidence comes from Oregon. Over 80 percent of people who have used this law have had end stage cancer. Of the remaining less than 20 percent, most of those either had end stage Lou Gehrig’s Disease or end stage emphysema. They knew. This is a lot more than a guess. Whether it was four months that they could have lived or six months, the point is they were dying…they were in agony and they wanted to hasten death because their suffering was intolerable.

Bob Oakes: John, why isn’t Oregon’s experience proof enough that it would be okay for Massachusetts to do this?

John Kelly: We really don’t know much about what goes on in Oregon. The data shows very little. All we hear from are doctors who voluntarily report that they prescribe the drugs. Now Marcia says that doctors don’t have to prescribe — why don’t we hear from doctors who in their medical judgment are not prescribing this medicine? Instead, people go doctor shopping. Many of the relationships between patients and doctors are very short.

Bob Oakes: Dr. Angell, how do you keep a patient from doctor shopping if the doctor the patient is using at the moment doesn’t want to participate?

Dr. Marcia Angell: A doctor should not then abandon the patient. It’s right for the doctor, who for whatever reason decides not to participate, to refer the patient to another doctor. You just don’t wipe your hands and walk out the front door.

Bob Oakes: As I understand it, there’s no mental health evaluation required in order to participate. Should a mental health evaluation be required for patients who are requesting assisted suicide because shouldn’t we want to know that it’s not simply depression driving that decision, that it also might be the pain that person is under?

Dr. Marcia Angell: You have a situation that brings about sadness anyway. But if two doctors believe that it is affecting [the patient's] judgment, then they must refer to a mental health counselor.

John Kelly: Doctors don’t seem to be thinking that many people need a referral. One out of 71 people last year were referred in Oregon for psychiatric evaluation.

Bob Oakes: Are you worried, Dr. Angell, that insurance companies will push for suicide in order to cut costs?

Dr. Marcia Angell: You have to trust the patient. If an insurance company says to a patient, “Hey, why don’t you kill yourself?” the patient would say no. There is no evidence in Oregon that insurance companies have weighed in on this one way or the other.

John Kelly: What we have here is a $100 treatment that will be the cheapest. We already have serious cost cutting pressures. We constantly hear about the costs of caring for people in the last year of their lives. And out in Oregon, we saw Barbara Chandler and Randy Stroup, two people with cancer, who were prescribed chemotherapies by their doctor, denied by Oregon Medicaid because Oregon Medicaid decided that it could not financially cover those treatments. Instead, they received a form letter in which it was noted that they were eligibile for assisted suicide.

Dr. Marcia Angell: Argument by anecdote doesn’t advance us very far. The data are overwhelming that this law is being used exactly as intended.

Bob Oakes: Is this necessary, considering that current law gives every person the right to refuse life saving treatment?

Dr. Marcia Angell: The fact is that this right is being used responsibly. And this law would apply to people to people who are not on some life sustaining treatment (like a mechanical ventilator) and who want some more active help in ending their lives.

John Kelly: Whatever alleged benefit there might be for a few is vastly outweighed by the dangers to the many and the change in consciousness that this bill calls for where death becomes a medical benefit.

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  • Kathy Kaditz




    This November, a Ballot
    Initiative will ask citizens of Massachusetts if the General Laws of our State
    should be amended to include the “Death with Dignity Act.”  This legislation would declare:


    the public welfare requires a defined and safeguarded process by which an adult
    Massachusetts resident

    who has
    the capacity to make health care decisions and who has been determined by his
    or her attending and

    physicians to be suffering from a terminal disease that will cause death within
    six months may obtain

    that the patient may self administer to end his or her life in a human a
    dignified manner….such a process

    be entirely voluntary on the part of all participants…”


    The Community Ethics Committee
    (CEC) is a diverse group of 18 Boston-area residents who meets regularly to
    study and advise the Harvard-affiliated hospitals regarding a community
    perspective on bioethics policy questions. 
    In the spring of 2012 the Committee engaged in an extended study of the
    Death with Dignity Initiative. Our goal was to understand the proposal
    ourselves, in order to help citizens of the Commonwealth become educated voters
    in November. Our efforts resulted in a White Paper about what we called
    “Choosing Medically induced Death”.  The
    Paper is a record of our discussions,
    carefully presenting balanced arguments on every aspect of the Initiative.
    Sensitive to the complexity of the question before us and the reality of widely
    divergent opinions within the community, as reflected within our own group, we
    sought to clarify the issues rather than take positions.  We did achieve clear consensus in two areas –
    the extraordinary value to suffering patients of palliative care services and
    the extraordinary value to our communities of a reasoned and open conversation
    about end-of-life decisions.




    Is Choosing Medically Induced
    Death a good thing or a bad thing?

    It’s good if you think granting a patient the right to choose how,
    when, and where to die is paramount in relieving a patient’s suffering at the
    end of life.  It’s bad if you think the
    unintended consequences of altering the profound and historical relationship of
    physician and patient based upon healing will cause distrust and uncertainty
    among many, including those who may be most vulnerable to abuse (the disabled,
    frail elders, and costly patients). 


    Who would benefit if
    this Initiative passes?

    The Initiative is directed to terminally ill patients – those who
    have received a medical diagnosis of less than six months to live.  They are those most profoundly affected by
    issues of death and dying and it is their particular sense of the values they
    bring to that final human experience that should govern the medical options
    available to them.  They are dying – or,
    in the alternative, they are living with the extraordinary awareness of the
    shortness of time left to live that life. 
    The choices surrounding how they live that terminal life are significant
    and should be honored and respected.




    Who could be harmed if
    this Initiative passes?

    Those who receive a terminal diagnosis and then choose a medically
    induced death are necessarily suffering from emotional turmoil and yet no
    mental health evaluation is required under the Initiative’s provisions.  While some felt that mandated mental health
    services were a necessary protection against abuses, others felt that such a
    requirement was patronizing and unnecessary. 
    Another concern raised about the Initiative was that many patients who
    would most benefit from the ability to exercise the choice to end life and die
    with dignity are precisely the ones who are not qualified to choose under the
    law’s provisions.  Examples of this
    excruciating dilemma are most notably found in those patients with ALS (at the
    time the choice makes the most sense, they lack the physical ability to
    self-administer the medication) or those with advanced Alzheimer’s (by the time
    they are terminally ill, they lack the mental capacity to make the choice).  Both
    patients and their families know the terrible and sure progression of their
    disease and both are excluded from exercising their right to die with dignity
    solely because of the cruel twist of fate that they become “terminal” too late
    to do anything about it.  The law offers
    them no comfort or relief.


    How is Choosing Medically
    Induced Death different from other End-of-life Treatment Options?

    It is probably fair to say the goal of everyone is a “dignified
    death” or perhaps more universally, a “good death” – one in which the dignity
    of the person is maintained, pain is well-managed, and familial and community
    supports are in place.  Care of all
    patients is immeasurably enhanced by the presence of medical care teams trained
    in palliative care.  Specialists in
    palliative care have well-developed skills in conducting constructive dialogs
    with patients and families about end-of-life issues and they bring needed
    expertise in pain management.   Choosing
    Medically Induced Death may become a less attractive option when easily
    accessed palliative care is in place, including palliative sedation (also known
    as continuous deep sedation to unconsciousness as comfort care until death).


    The CEC observed that although suicide cannot be considered a
    medical treatment option, there are many non-medical ways to commit suicide and
    the result is the same.  In contrast to
    choosing medically induced death, choosing self-inflicted suicide can result in
    distinctly undesirable consequences. 
    Unfortunate insurance exclusions are triggered by suicide and tragically
    bad outcomes can be caused by failed suicide attempts.  There is some sense that condoning medically
    induced death will avoid the undesirable consequences of self-inflicted
    suicide, at least for those patients who are qualified under the Initiative.


    How should I vote?

    The concerns about who could be harmed by allowing patients to
    choose a medically induced death are balanced by concerns for people who have received the
    news that they will not live another full year. 
    We are, as a society, trying to find a way to honor their choices while
    protecting those others also involved in this process of death and dying – the
    medical community who have committed themselves to the healing arts; friends and
    families who must come to terms with the fact that a loved one’s choice of how,
    when, and where to die is not their choice; and the rest of us who are defined
    by how we protect the weakest among us.


    For a conversation guide go to http://www.medicalethicsandme.org
    Kathy Kaditz
    CEC Member

  • http://pulse.yahoo.com/_S65RBEEMYRFYVMJZMRRADQMMAI gardenia

    I approve of the”Death with Dignity Act”.  Dying a slow, debilitating, painful death is abhorrent to me.  However, it may not be for everyone, especially if the dying person does not understand what is happening.  I hope a loved one of mine gives me an overdose of pain/sleep meds if I am near the end and can ask for it.

  • Ronpies

    It is important to distinguish a competent individual’s liberty to end his or her life, from a supposed “right” to physician-assisted dying. The terminally ill person who is in full possession of her mental faculties may indeed be at liberty to cease medical care and end life by, for example, refusing food and drink. Contrary to a popular myth, this does not create a painful or uncomfortable death, and is a recognized means of ending life in palliative care medicine. But there is no justification, in my view, for a physician’s “assisting” in a patient’s death. This not only contravenes the physician’s duty to heal, but also undermines the social contract between the physician and society at large. It is of course the physician’s role to minimize pain and suffering near the end of life, and to provide comfort and counsel to the patient and family.

    Ronald Pies MD

  • Jasoturner

    Nobody’s getting out of here alive.  To deny rational people a means of ending their terminal suffering, and the suffering inflicted on their loved ones, is cruel and hubristic to the extreme.  Each individual can and should be able to make this choice. Denying them this option is to play god, whether you like it or not.

  • Thaddeus Mason Pope

    The last question posed to Mr. Kelly and Dr. Angell is “Is this necessary, considering that current law gives every person the right to refuse life saving treatment?”  

    The answer is “yes.”  Not all terminally ill patients, living lives that they themselves find intolerable, are dependent upon life-sustaining treatment.  There is, in other words, nothing to “turn off” or “stop.”  I explain this further in a 2011 law review article here.  http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1689049

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