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Marcia Angell

A method for dying with dignity

On Nov. 6, Massachusetts voters will decide whether physicians may provide a dying patient, whose suffering has become unbearable, with medication to bring about an earlier, more peaceful death if the patient chooses and the physician agrees. On the ballot will be a Death with Dignity Act — Question 2 — that is virtually identical to the law that has been in effect in Oregon for nearly 15 years.

Good palliative care is adequate for the great majority of dying patients, but not all. Most pain can be eased, but other symptoms are harder to deal with — weakness, loss of control of bodily functions, shortness of breath, and nausea — and the drugs to treat these symptoms often produce unacceptable side effects. Even worse for many dying patients is the existential suffering. They know their condition is inexorably downhill, and they find it meaningless to soldier on.

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This is not a matter of life versus death, but about the timing and manner of an inevitable death. That is why many prefer the term “physician-assisted dying” to “physician-assisted suicide.” In the usual suicide someone with a normal life expectancy chooses death over life. Terminally ill patients don’t have that choice.

Like the Oregon law, Question 2 contains a host of safeguards. It applies only to adults able to make their own decisions, and the patient must be capable of swallowing the medication — usually barbiturates dissolved in a full glass of liquid — which helps ensure that it is voluntary. Euthanasia (the injection of a lethal medication) is not permitted. The patient must have a terminal illness, with a life expectancy of no more than six months, as determined by at least two physicians.

The patient is to make two oral requests for the medication, separated by at least 15 days, and one written request, with two witnesses. If a physician believes a psychological condition is impairing the patient’s judgment, the physician must refer the patient to a psychiatrist or other licensed counselor. No physician is required to participate; they may refuse for any reason whatsoever. This is a choice for both patients and physicians.

Nearly everyone knows someone who has wished for an earlier death while suffering from a terminal illness, and polls show that most people believe physicians should be able to help such patients die. But we are now being barraged by warnings that the Death with Dignity Act will put us on an ethical “slippery slope” leading to the widespread coercion of vulnerable patients to end their lives, even when they may not be dying and their suffering could be relieved.

The best answers come from Oregon. Assisted dying there has accounted for 596 deaths over the past 14 years, only 0.2 percent of all deaths in the most recent year. Most of these patients were suffering from disseminated cancer, and the prognosis was clear. Far from being vulnerable, they were relatively affluent, well-educated, and well-insured, and nearly all were receiving good hospice care. They were no more likely to be depressed than other dying patients, and there was no evidence of coercion by unscrupulous families. About a third of patients who received medication didn’t use it, but kept it at hand for peace of mind. No law works absolutely perfectly, but this one comes about as close as possible.

This is not a matter of life versus death, but about the timing and manner of an inevitable death.

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Unfortunately, the Massachusetts Medical Society officially opposes the Act because it believes it is “inconsistent with the physician’s role as healer,” in the words of its past president. But this isn’t about physicians or their self-image; it’s about patients — specifically patients for whom healing is no longer possible. They, not physicians, are the ones to say when their suffering is no longer bearable, and individual physicians (many of whom disagree with the position of the medical society) should be able to honor their wishes. Why should anyone — the state, the medical profession or anyone else — presume to tell someone how much suffering they must endure as their life is ending? We respect people’s right to self-determination when they’re healthy. That shouldn’t be denied to them when they’re dying.

Dr. Marcia Angell, former editor-in-chief of New England Journal of Medicine, is senior lecturer in social medicine at Harvard Medical School.
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