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editorial | ‘DEATH WITH DIGNITY’

End-of-life discussions, care should come before Question 2

Massachusetts, like most of the United States, has been in a woeful state of denial about the way its medical system handles the end of life. Too often, doctors shy away from frank discussions with terminally ill patients about their options — from continuing treatment, to palliative care, to some combination of both. Worse, society is so scared of such conversations — so conflicted about how far doctors should go in declaring a patient’s condition to be terminal, so reluctant to ever give up hope — that many insurers, including Medicare, don’t even cover the cost of an end-of-life conversation. Instead, they keep plowing money into treatments, while too many lives end in hospital beds, after unnecessarily painful side effects from unsuccessful drugs and devices.

Now, like a clanging wake-up call, comes the Question 2 “death with dignity” ballot initiative, which would establish procedures under which doctors could prescribe life-ending drugs to terminally ill patients. It draws heavily on the experiences of the two states that allow so-called physician-assisted suicide, Oregon and Washington. But it’s not, in itself, an answer to the far deeper question of how to help patients make end-of-life decisions.

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Even in Oregon, which first approved physician-assisted suicide in 1994, only 71 people took advantage of it last year. Most were cancer patients. But many other dying patients, from those with degenerative physical conditions like Lou Gehrig’s disease to those with mental deterioration from Alzheimer’s and other conditions, weren’t eligible because they couldn’t satisfy both the requirement of mental fitness and the ability to administer the drugs themselves.

And rather than bring society to a consensus on how to approach the end of life, Question 2 adds new and divisive questions to the mix: Should doctors actually help people die more quickly, rather than merely withhold treatment? Does such a regimen serve to weaken society’s belief that lives — even those of the seriously ill, or severely disabled — have value and are worth living?

Such questions draw on individual beliefs and morals, and defy practical analysis. Reasonable people can disagree passionately about Question 2, but a yes vote would not serve the larger interests of the state. Rather than bring Massachusetts closer to an agreed-upon set of procedures for approaching the end of life, it would be a flashpoint and distraction — the maximum amount of moral conflict for a very modest gain.

Instead, Massachusetts should commit itself to a rigorous exploration of end-of-life issues, with the goal of bringing the medical community, insurers, religious groups, and state policy makers into agreement on how best to help individuals handle terminal illnesses and die on their own terms.

Most importantly, patients need a realistic assessment of their disease, its prognosis, and the range of treatment options before them. Access to palliative care, psychiatric therapy, and hospice nurses are already covered by Medicare and most insurers. Such services may sound elaborate, but are actually far less costly than the intensive care that so often attends last-ditch treatments.

A yes vote would not serve the larger interests of the state.

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Physician-assisted suicide should be the last option on the table, to be explored in a thorough legislative process only after the state guarantees that all its patients have access to all the alternatives, including palliative care. Question 2, which would require that two licensed physicians confirm that patients have less than six months to live but are competent to make their own decisions, has drawn the opposition of the Massachusetts Medical Society, which argues that physicians shouldn’t be put in the position of ending people’s lives.

Further, the society argues, physician-assisted suicide is unnecessary in light of patients’ “right to refuse lifesaving treatment, and to have adequate pain relief, including hospice and palliative sedation.” The medical society’s position is reasonable, but too few patients get the information necessary to assert those rights. It’s up to the state’s physicians to take the lead in making sure that patients are aware of their options and take full advantage of them; all available evidence suggests that many more would do so, if only they had the proper information and encouragement.

Then, and only then, would the need for physician-assisted suicide become apparent. If the process of dying becomes more manageable, more dignified, and more comfortable, then fewer patients would seek to hasten it along. Doctors would be spared a vexing set of decisions. The seriousness with which the state is approaching Question 2 is, in itself, an indictment of the current state of end-of-life care. More than a cry for physician-assisted suicide, it’s a plea for greater dignity at the end of life. And that request, at least, should be answered.

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