Death with Dignity: A Response to Daniel Callahan

As someone who strongly supports the proposed Death with Dignity Act that will come before Massachusetts voters on November 6th and that is virtually identical to the law that has been in effect in Oregon for nearly 15 years and in Washington state for four years, I would like to respond to Dan Callahan’s arguments against it. 

This law enables terminally ill patients who find their suffering no longer bearable to ask their physicians for a prescription for medication that they can self-administer to bring about an earlier, more peaceful death. Good palliative care is sufficient for most dying patients, but not all. Pain can usually be eased, but other symptoms – weakness, loss of control of bodily functions, nausea, and difficulty breathing –  are harder to deal with. Add to that the awful knowledge that the course is inexorably downhill, that no matter how bad it is today, tomorrow will likely be worse.  Still, in its  14 years, through 2011, the law has been used by only 0.2% of dying patients in Oregon, nearly all of whom were on hospice care.

Two important points:  First, this law is not about someone with a normal life expectancy choosing death over life, as in the typical suicide. All of these patients have fatal illnesses which will cause their death in a matter of months. The only question is the exact timing and manner of an inevitable death. That is why proponents prefer the term “assisted dying” over “assisted suicide.” Second, no doctor is required to comply with a request for assisted dying; this is a choice, not a requirement, for both patient and physician.

Unfortunately, most of Callahan’s arguments do not address the substance of the law itself, but a variety of extraneous issues. For example, he denounces practices in the Netherlands. But the main form of assisted dying there is euthanasia, not assisted suicide, and it is not restricted to patients with a terminal illness.  Also, euthanasia did not become legal in the Netherlands until 2002.  Until then, even though physicians who performed euthanasia were unlikely to be prosecuted, many were still reluctant to report it.  That is why physician surveys were necessary to get some estimate of the incidence. (Callahan refers to a 1991 report that indicated there were 1,000 instances in which physicians performed euthanasia without patients’ concurrent consent. Most of those cases involved patients within hours to days of death, who were no longer alert but had earlier said they would want euthanasia in that circumstance.)

But the Dutch experience, whatever it is, is not relevant to the experience in the United States, where euthanasia is illegal and there are ample safeguards to ensure that all deaths from assisted dying are voluntary and reported. Thus, surveys of physicians would provide no added information about the use of the law.  They might tell us something about how often physicians hastened death in other ways, such as by giving large doses of morphine, but that would have nothing to do with the law, and there would be no reason to suppose extralegal practices are more common in Oregon and Washington than in other states, and some reason to think they’re not.

The rest of Callahan’s argument has to do with language, not substance. I prefer the term physician-assisted dying to physician assisted suicide, for the reason I said, but that is really something of a side issue. Callahan also dwells on the word “dignity.” As someone whose father shot himself rather than continue to endure a protracted death from cancer of the prostate, I agree with Callahan that his death was no less dignified than if he had had the option of physician-assisted suicide and chosen that instead.  It was also no less dignified than if he had chosen to die from his cancer. It seems to me that what is or is not “dignified” is entirely up to the patient who is experiencing the suffering.

Many in Oregon say that they are experiencing a loss of dignity, and that is for them to say.  My point here is that while the word “dignity” has been attached to these laws over the years, that, too, is a side issue.

Some conservative religious and philosophic traditions oppose physician-assisted suicide as a matter of doctrine, but I see no justification for imposing that view on others. In my view, what matters is who should make the decision about how much suffering is too much – the patient or someone else. There is something bullying about telling dying patients who are in agony and asking for a quicker death that they must continue to soldier on. More than any other personal decision I can think of, this one  belongs with the patient.

Marcia Angell, M.D., 73, is a senior lecturer in social medicine at  Harvard Medical School and former editor-in-chief of the New England Journal of Medicine. She is the lead petitioner of the Massachusetts Death with Dignity Act.

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