Massachusetts ballot questions: Question 2

[xiphias]

Question 2 is a four-page monster that deals with physician-assisted suicide. The four pages are because it's got tons of different sections trying to anticipate ways that such a law could be abused and to try to limit its abuse potential.

And this one is a bit more of a question for me. For a lot of reasons.

The first thing is that I'm not entirely clear how I feel about human euthanasia. At all. And I'm not sure how I feel about suicide. At all. So I'm REALLY not clear how I feel about euthanasia-by-suicide. And I'm absolutely sure that I'm not clear on whether this proposed law actually WOULD protect against abuse. I mean, it's bringing up protections against forms of abuse I hadn't even considered, which is good and all, but it makes me even more certain that there are forms of abuse that HAVEN'T been considered by the writers of the law.

I'm truly on the fence about this.

Here's what I'm certain of: in this country, we ABSOLUTELY don't do enough with pain medication. We are willing to have untold numbers of people suffer, because of the possibility that someone, somewhere, might use those medications to entertain themselves instead of using them for pain management. There's something in our national psyche that believes that "suffering is good and makes us stronger", and is dubious about relieving suffering.

Obviously, this point will come up again talking about the Medical Marijuana question, but it's relevant here, too.

This law is limited to mentally competent adults who have no more than half a year left. If such people knew that their pain and discomfort could be genuinely alleviated for half a year, that might make the prospect of checking out early less appealing.

My mother is a hospital chaplain who works with hospice patients, and I've talked with her about this, too. And, like me, she doesn't see this as an easy or obvious question, either.

Well.

What about the moral questions around suicide, and around euthanasia? When you get right down to it, physician-assisted suicide kind of swirls a whole bunch of moral questions into a truly confusing grey area.

Let me start with "suicide".

I believe that the fundamental human right, the one that all other rights spring from, is the right of self-determination. People have the right to live their lives as they choose, so long as doing so doesn't impinge on the rights of others. And that would appear to imply that people have the right to end their own lives at the time and in the manner of their own choosing.

And yet.

I have had a friend involuntarily confined to a mental institution because zie was suicidal. Zie is alive today, and remembers very, very little about that whole time period, and we believe that I did the right thing. I believe I did the right thing.

But I don't know WHY I believe that I did the right thing. At the time, zie was arguing that I had a moral responsibility to respect zir right to self-determination and allow zir to commit suicide.

And I didn't, and don't, have a counterargument to that. When I take my ethical postulates, and follow them through my ethical calculus, it comes out that I was supposed to let zir die. And I didn't do that, and I KNOW that I was RIGHT not to do that, and I don't know why.

When I take my ethical postulates, and follow them through my ethical calculus, it comes out that a terminally-ill patient has the right to choose the time and manner of zir death. And that seems reasonable to me.

But I'm scared off of that conclusion because I'm sure that there's a difference between the terminally-ill patient and my depressed friend. But I can't put my finger on exactly WHAT that difference IS. And until I can figure out why one case is moral and the other isn't, I can't really be sure that one case actually IS moral, and the other case actually ISN'T moral.

I DON'T want to interfere with the right of self-determination of a terminally ill patient. And, well, if that right does include the choice to end life, that person certainly should be offered ways that are as painless and dignified as humanly possible.

But . . .

Edited to Add: if you're just skimming this, click through to the comments. They're ALL worth reading, but I especially want to point out both tikva's and metahacker's. If you can read BOTH of those and STILL be sure what you believe. . . well, I don't know what the "then" clause would be. They both make 100% compelling arguments to vote in opposite ways.

Comments

[undauntra.livejournal.com]

Do you see a difference between the decision-making ability of someone who is depressed versus someone who is terminally ill?
Do you see a difference between friends and family making the decision on behalf of an individual, the state making the decision on behalf of an individual, and the medical profession making the decision on behalf of an individual?

[xiphias.livejournal.com]

I do see all of those as differences, but I don't know which, if any of them, are critical.

I probably should actually talk to the friend in question, come to think of it, because, among other things, zie has studied -- and, indeed, taught -- bioethics.

[tylik.livejournal.com]

I don't know the details of the law in question.

I generally support physician assisted suicide in the case of terminal or untreatable conditions. I did so even before I read through the results of the law in Oregon (which among other things led folks to get more serious about end of life care, because apparently people really don't like the idea of people killing themselves because they are miserable in non mandatory ways outside of their control).

I will intervene in suicides - at least some of the time. Probably most. I used to be much less clear in this, but then, in the wake of a 15 year old girl jumping off a bridge and landing essentially in my driveway (when I lived on the house barge) I did a bunch of reading. And basically, people who choose the mostly likely to be lethal forms of suicide are usually acting on short lived impulse, and if they do no succeed, 90% will not try again. (And they rates of attempts go down tremendously if you can do things to make suicide even minorly more difficult - the research is fascinating.) If someone is intent over the long term on killing themselves (I'm thinking of someone with full mobility and suchlike) there are plenty of ways to do it, and do it without involving me in it. But for most cases, if someone is involving me, they are in effect making me complicit (and may be indirectly asking for intervention)... and yeah, maybe they'll hate me later, but I will act. I don't expect them to thank me later, but most of them will be glad to be alive.

(As a note - and I'm falling asleep here - this is consistent with other matters in which I come out feeling that if I have been implicated in something I'm now part of it. Such as how I feel about people trying to non-consensually obligate me to keep inappropriate secrets.)

But someone who has maintained their wish to die over a period of time? Especially someone who has had a psychological evaluation and whatever other measures? (I'm not convinced they should be necessary, but certainly they're comforting.) To me that is entirely different.

[kalmn.livejournal.com]

rivka at respectful of otters changed my thinking on this. (which is to say that i am now not sure what i think.)

http://respectfulofotters.blogspot.com/2005/03/terri-schiavo-part-ii-ethical-post.html

you can read that one, but i mostly link to it because of the links in the first sentence-- hit them all.

[papersky.livejournal.com]

That is exactly what I was going to say and link to. Thanks!

[quietann.livejournal.com]

I'm tired, and in no mood to go looking up references, but the Oregon experience has shown:

a. End of life pain management in Oregon has *improved* since the law was passed

b. A fairly high proportion of people who use the law to request and obtain the meds to kill themselves end up not using them. Sometimes just having the option is all someone needs.

The proposed law has a lot of safeguards built in. I do not consider people who end their lives this way to have had euthanasia.

[metahacker.livejournal.com]

These things. Especially #a. It's less about people offing themselves, and more about giving them a feeling of control over their life. And in some cases, letting them choose a pleasant time and place, and an inexpensive end.

And as someone deeply affected by this issue in a very personal way, let me just remind you (xiphias) that sometimes the alternative to assisted suicide is unassisted suicide; and other people *always* end up dragged into that (sometimes overtly, as in suicide by cop, sometimes indirectly, as in the people who must find the body and untangle the mystery/misery).

[stitchwhich.livejournal.com]

"sometimes the alternative to assisted suicide is unassisted suicide; and other people *always* end up dragged into that (sometimes overtly, as in suicide by cop, sometimes indirectly, as in the people who must find the body and untangle the mystery/misery)."

True. As I learned when I was first diagnosed with my cancer and was thinking about a way to Check Out that would not seriously impact more than just my family members (who are all, as I am, of a mind that they do not wish to be bound to a bed with tubes keeping the engine running while the mind rots away). I could not think of a way to achieve my own end without also inducing mental trauma in someone else - specifically, those who'd find, or have to deal with, the body.

[(Anonymous)]

Being ill and deciding on what treatment or how much treatment is a right adults have. Making decisions on living wills and other end of life issues often happens when one makes a will and therefore those decisions are made while the person is in good health and of sound mind and body. It is the phrase sound mind that differentiates between the right of an ill person to determine if and how to treat a future illness. Most people feel that being suicidal is not of sound mind and therefore intervention is called for. If you listen to some of the advertisements for medications, suicidal thoughts are sometimes called out as side effects. One needs to make sure that a person wanting to commit suicide is of sound mind by a quantifiable method and then it can be allowed.

[xiphias.livejournal.com]

Is there such a thing as a quantifiable method to determine a sound mind? Is there a clear definition of "a sound mind"?

[awfief.livejournal.com]

Especially since US culture seems to legislate that if one is suicidal, they are *not* of sound mind, regardless of the conditions.

[(Anonymous)]

In order to allow suicide it may be necessary to have a definition of a sound mind and a national discussion on the issue.

[thnidu.livejournal.com]

Having a discussion presupposes that the participants are willing, at least potentially, to be convinced. For example, there's no use trying to convince a fundamentalist that Darwin was right, because the fundie's logical operations all begin with "The Bible is correct, word for word [in the translation I'm using]", and therefore anything that contradicts it must be wrong.

[ellettra.livejournal.com]

There are quantifiable methods for determining competency built into the law.

One thing that needs to be clarified in this discussion is that depressed people who commit suicide are not the people who are using this law. The people using this law have been evaluated using strict guidelines and meet the criteria. And they only have six months to live, or less, with zero hope of recovery. The difference between that person making a well-reasoned decision to end their life on their own terms in a dignified manner (it is essentially going to sleep) and a person who is despondent jumping off a bridge are myriad.

[tikva.livejournal.com]

I really will post my Long, Noodly Post about this issue soon, before people vote, but I personally will be voting against this bill. I do believe that people have the right to end their lives as they choose, and I also agree that pain management just plain doesn't work for a lot of people. But I also know that we live in a country with a for-profit health care system, where insurers can choose to cover assisted suicide but not treatment. That erases any notion of "choice" for poor people. I also know that I live in a world that tells me that as a person with a disability, my life is worth less, and we are often pressured to die or assumed to be sicker than we are. A friend of mine with quadriplegia was in the hospital for pneumonia for a few days and was asked three different times if he wanted a DNR. When's the last time you were asked if you wanted one? There are safety measures, yes, but they're fairly easy to bypass with family pressure and given that many doctors view the quality of life of people with disabilities as necessarily lousy. If you're walking around loose and want to kill ourself, they give you suicide prevention interventions. If you're in a wheelchair and want to kill yourself, they wonder why you waited this long. I don't trust the system to help people die with dignity because, frankly, it's crap at helping people live with it. And yes, I've seen people die slowly, and it sucks. (In fact, your mom was the hospital chaplain who helped us when my dad was on his deathbed, and I will always appreciate that).

So that's my take on it. YMMV, of course.

[nancylebov.livejournal.com]

One more angle: we live in a country with a war on drugs, which means that pain medication is much less available than it should be.

[kerrypolka.livejournal.com]

If you're walking around loose and want to kill ourself, they give you suicide prevention interventions. If you're in a wheelchair and want to kill yourself, they wonder why you waited this long.

I totally agree, and although I'm pretty sure I'm in favour of people having the option of medically assisted suicide in abstract, I feel it would unquestionably increase pressure against people with disabilities to off themselves, so I'm mildly against it in practice until society is less ableist.

[xiphias.livejournal.com]

. (In fact, your mom was the hospital chaplain who helped us when my dad was on his deathbed, and I will always appreciate that).

I didn't know that. My mother doesn't give identifiable details about individuals when talking about work, because a) medical ethics, b) chaplaincy ethics, c) personal disinclination to gossip.

[amaebi.livejournal.com]

Yow. I hadn't thought of that.

[awfief.livejournal.com]

I do know that poor and/or disabled folks are being pushed towards death faster than able-bodied and wealthy folks are. I don't think eliminating a choice because it is another tool to oppress folks is a good idea. We should work on getting rid of that oppression, not the tools, because all tools can be misused/abused, ya know?

[ellettra.livejournal.com]

I think it's important not to forget that the only people who are able to avail themselves of this are those who have been determined as terminally ill, by two separate doctors, and who ONLY have 6 months to live. I would be very surprised to see evidence which supports the conclusion that assisted suicide pressures those living with different/disabilities to hurry up and off themselves.

That said, I do believe that we live in an ableist society. I just think it's a completely different issue which serves primarily to cloud the overarching theme, which is giving people a way to control their own destinies.

[maggiebloome.livejournal.com]

I think of it this way - when you make a long term decision, you're making a decision about what is best not just for you, but for all the iterations of your future self. In fact that's pretty much the definition of a "long term" decision - if your future selves regret it/get more harm than good out of it, you generally think of it as a bad decision.

One of the symptoms of depression is a block in your ability to do long-term thinking - that's one of the reasons you feel so bad, because you can't imagine that you will feel better at some point in the future. So, a depressed person is pretty likely to make decisions that a number of their future selves will not approve of.

When you stopped your friend from committing suicide, you were acting on your reasonable assumption that the balance of zir future selves would rather exist than not. Since zie now thinks you did the right thing, your assumption was correct. When a person is terminally ill, there aren't a lot of future selves left, and most of them will be in a situation equally shitty to the one present-self finds themselves in. This tips the balance of probability somewhat.

You can extend this logic to other self-destructive behaviour, of course, and it's a matter for debate how far exactly it goes. Death is fairly irreversible, though - there are not a lot of other bad decisions that someone can't fix or at least mitigate the effects of, and there aren't a lot of unambiguously bad decisions that don't impinge on anybody's rights. It's hard to make a good guess as to what somebody's future selves will think about their tattoo, but it's pretty easy to assume that they'd like to live.

[cbpotts.livejournal.com]

I think it is hard for some people (obviously I know not you) to believe that depression is a disease, period - people are told constantly to just cheer up and think happy thoughts and everything will be fine. To accept that there can be terminal depression, that your brain chemistry can in fact kill you just as surely as cancer and blood clots in the brain, is far further than many people are willing to go.

I do not have a clear position on legalizing euthenasia. I believe that there is de facto euthenesia going on all of the time; the poor, the inconvenient, the without-connections and resources, do not receive the same standard of care - or care at all - as those with resources. We just don't talk about how in America people die from an abcessed tooth. People who are significantly disabled are not so subtly encouraged to opt out to relieve the burden on their families/society. It's not a long walk from euthenasia for the terminally ill for the euthenasia for the too expensive to treat, especially for 'that type' of person. (You can fill in 'that type' with so many different descriptors)

At the same time, I grew up on oncology units. I know for a certainty that back in the day, physicians would mention, clearly as a 'caution', exactly how many painkillers it would take to kill you, and how many would leave you still alive and more fucked up, and write scripts for more than enough to finish the job. I think a more formalized, less ambiguous structure that wouldn't leave patients reading between the lines, and with surviving families members with a certainty to deal with rather than 'it was a mistake!' might be nice. Also, I am not sure if there would be a more instant, less prone to painful failure method of checking out than taking all the pain pills and making sure you don't wake up.

[xiphias.livejournal.com]

My mother told me that a lot of the people who work in hospice have "Those Pills" set aside somewhere, Just In Case. Which is yet another one of those pieces of information which makes the whole picture so confusing. Everything I learn about this makes me more and more confused.

I mean, I look at Tikvah's comment; I look at Metahacker's comment -- they're both such good points.

[quietann.livejournal.com]

Also, a lot of *doctors* have the Just In Case meds set aside, and clear instructions to family members about what to do if the doctor isn't able to do it him- or herself.

To let you know just how effed up end of life care is here, I also know doctors who have "DNR" tattooed on their wrists and chest. And a lower percentage of doctors die in hospital, compared to the general population.

[janetmiles.livejournal.com]

I have wanted, for decades, to have DNR tattooed on my chest in big block letters. My husband objects vehemently, and so I have not done so.

That's also why my living will is much more complicated than I really want: what I want is, "Do Not Resuscitate In Any Way Under Any Circumstances, EVER." What I've got is, "If I am in a persistent vegetative state, comfort care only and DNR."

[vass]

Here via browngirl.

My impression is that doctors and nurses, because of their mission, training, and experience, are actually worse at confronting both disability and mortality than the general population. They're trained to see their job as 'fixing' people, returning them to 'normal'. So they don't do well with people who were never normal, or who can't be made normal, and they really do badly with people dying. I read a book by a surgeon about that a few years ago, Pauline Chen's Final Exam. She wrote that she'd received no training at all about end of life issues.

I remember a few years before my grandmother died, she got bronchitis and the doctors gave her antibiotics, and my aunt, who was a nurse, said that they shouldn't have done that. My grandmother had a 'no heroic measures' note, but neither her doctors nor the rest of the family saw antibiotics (at that particular stage) as a heroic measure. My grandmother had dementia, but if you'd asked her "do you want to die now" she both could and would have said no. (Nobody did.) My aunt just personally judged that her mother's condition was bad and therefore she should not be saved.

[awfief.livejournal.com]

My take on it is that this is something the medical establishment is pushing. And while they *might* be pushing so they can pressure folks into death instead of life, as tikva points out, I think the reason the law is coming up now is to protect the doctors (who are already doing this) from being sued, by making it legal.

There are unintended consequences, to be sure. Poor folks are already pushed towards death anyway, and I think we need to reform THAT as opposed to saying "This is just another medical thing that can be used to oppress poor people." Because if we do that then we have to say that for every drug approved by the FDA, etc.

[browngirl.livejournal.com]

This is one of the most useful and edifying discussions I've ever read in your joutnal, and that's saying a lot.

[purlewe.livejournal.com]

I came by way of browngirl, and I have found both your notes and the comments very interesting.

I find, the older I get, and the more I see people suffering needlessly, the more likely I am to opt out of medical health care. I have personally seen members of my family get pacemakers, then - several yrs later- get a debilitating illness and the pacemaker is the only thing keeping them alive. They have died, more than once, more than TWICE! and yet the doctor's refuse to remove the pacemaker b'c it is unethical. HELL one uncle had to undergo surgery to replace the battery for his pacemaker EVEN THO he had died and been brought back to life by the thing. Natural death is a rare thing in our westernized medicine.

Our culture doesn't accept death as an answer to anything. They refuse to let people who have illnesses to die peacefully. Doctors, too afraid of lawsuits and full of ego, think that they can fix things that cannot be fixed. I feel for folks who want out of that loop and wish to focus on themselves and their family with a good and peaceful death. Yes, there needs to be screening to make sure that this is not done incorrectly, but really a peaceful death is so hard to find these days. I hate to refuse someone's right to it.

Thank you for making me think about this.

[xiphias.livejournal.com]

At this point, it's hard to even define what "natural death" actually IS.

[chienne-folle.livejournal.com]

I'm sure that there's a difference between the terminally-ill patient and my depressed friend. But I can't put my finger on exactly WHAT that difference IS.

I think the difference is how likely it is that the person might change their mind, later, if they were forced to live. Your depressed friend might get better -- and did. The terminally-ill person will not get better. The terminally-ill person could still change their mind later, because human beings do that, but their entire situation is unlikely to change for the better, whereas if you add medication and/or therapy to a depressed person, their situation could become entirely different.


(Pointed here from Browngirl's journal)

[ellettra.livejournal.com]

We've got this law here in Oregon already, and I've gotta say that there's a helluva lot more hullabaloo around it in theoretical terms than in actual practice. The percentage of people who actually use the medication is very low. Many people have the Rx filled and do not use it, either because they decide not to (that having access to it is enough), or they wait too long and are incapacitated to the point where they are unable to self-administer. Regardless, no death panels have ever been formed, and there was never a line of terminally ill seniors lined up at the borders for their koolaid.

Unless a person has religious objections (which I don't personally feel to be valid in the case of inserting your opinion into someone else's end of life), I can't understand why someone would deny a person the right to determine the moment of their own death, and in a manner which is dignified. The law is extremely clear, and the safeguards are in place and are extremely effective (almost cruelly so, in some cases, for example, Alzheimers patients will never be granted the medication because when they've only got 6 months to go, they don't have the mental faculties to make the decision, even though Alzheimers is such a wretched horrific way to go). It's not a matter of IF a person will die, it is merely a matter of when. It's a very very short window of SIX MONTHS.

And honestly? This happens ALL THE TIME with or without a law in place. All the time.

[ellettra.livejournal.com]

I forgot to add as well that the process for requesting the medication is quite involved. Two separate doctors have to sign off on a terminal diagnosis, as well as on a mental evaluation. The request has to be made 3 separate times, and separated over a certain period of time (several weeks). The final request must be in writing and must be witnessed by people who are neither physicians involved nor family members. So it cannot be a spur of the moment decision, and cannot be made by people who are psychologically fragile. You should also check out the statistics on the educational level of people who have used the medication. It's something like 90% college-and-above educated.

[xiphias.livejournal.com]

Well, frankly, what I have ARE moral/ethical objections, which ARE influenced by my religious upbringing. Our laws ARE ways in which we express what we, as a society, consider acceptable, which is why many people are comfortable with people using drugs so long as it's not legal for them to do so. It's not that they object to drug use: rather, they object to CONDONING drug use. Or gay relationships, or whatever.

And, frankly, there's a big part of me that is attracted to that line of reasoning. There's a part of me that is a lot more comfortable with this happening all the time without a law in place, rather than giving the practice official sanction. There's a part of me that considers hypocrisy to be a useful tool in maintaining a stable society.

Yeah. There's a real sense in which I don't object to the PRACTICE of suicide as a response to terminal illness, but I do feel uncomfortable with giving the practice the legal imprimatur. There's a real part of me that wants it to exist, but remain in the shadows.

Yes, of course that's hypocritical, and I'm aware that it's not a stable or healthy way for a society to operate.

[ellettra.livejournal.com]

Well, society limps on, even with a plethora of divergent opinions. That's really what makes this country great, at the risk of sounding ridiculously patriotic. :)

[403.livejournal.com]

My thoughts and feelings on assisted suicide are complicated, but I don't even need to get into them to decide to vote "no" on prop. 2. The bill has no provision requiring an uninvolved witness at the time of death - it would be perfectly acceptable for an heir, or someone else who stands to benefit from the patient's death, to be the only other person present. If that's not an opening for abuse, I don't know what is.

[xiphias.livejournal.com]

No, that one is covered.

Section 3, Paragraph 2:

(2) At least one of the witnesses shall be a person who is not
(a) a relative of the patient by blood, marriage, or adoption;
(b) a person who at the time of the request is signed would be entitled to any portion of the estate of the qualified patient upon death under any will or by operation of law; and
(c) an owner, operator, or employee of a health care facility where the qualified patient is receiving medical treatment or is a resident.

That one, at least, they DID think of.

[403.livejournal.com]

I missed that when I skimmed the text. Thanks!

[xiphias.livejournal.com]

Yeah. As bills go, four pages isn't actually that long. For, y'know, full-time legislators who have interns and staff and stuff who can go through the bills line-by-line with help.

For the rest of us, though, it turns into a wall of text. I like ballot initiatives in theory, but, well, actually reading them all closely enough to really know what is in there, and to understand it?

Not as easy as one would like.