Death with Dignity: A Response to Daniel Callahan

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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.

4 Responses to “Death with Dignity: A Response to Daniel Callahan”

  1. Lydia Dugdale

    I will respond to Dr. Angell’s “two important points.”

    Her first is that the proposed law is not about “typical suicide,” but it is worth noting that in Oregon, the rate of “typical suicide” has steadily increased since 2000. Oregon’s “typical suicide” rate is 35% above the national average and Portland is rated one of the most suicidal cities in the United States. The Oregon Department of Health and Human Services has published on the web a 46-page document entitled “Suicides in Oregon” with much more data. Is it simply a coincidence that Oregon’s “typical suicide” rate has steadily increased with the legalization of physician-assisted death?

    Dr. Angell’s second point is that no doctor is required to comply with a request for assisted dying. While this is undoubtedly a relief to those who oppose physician-assisted suicide on moral, religious, or philosophical grounds, I do not understand how this qualification in any way legitimizes the act. Neither does she say. As a practicing physician, it has been my observation that medicine has become too much about doing and not enough about thinking. Is there no value to wrestling with existential questions?

    Dr. Angell systematically dismisses “religious and philosophic traditions oppos[ed to] physician-assisted suicide as a matter of doctrine,” by explaining that she sees “no justification for imposing that view on others.” But surely this is more than a matter of choice. What does it mean to be a physician, to heal? What does it mean to be trusted by society to care for the most vulnerable? And does Dr. Angell’s own position not in fact presume an extraordinary confidence as to the source of life’s meaning – a confidence that is itself ultimately a matter of doctrine?

  2. Robert Liner

    As a physician and one who supports physician aid in dying as proposed by Question 2 in Massachusetts, I can speak to Ms. Dugdale’s questions about what it means to be a physician. For me, it means trying one’s best to “heal” when healing is possible, but to comfort always. Ultimately, death isn’t curable, but being a doctor can mean staying with a patient to the very end. It means listening to patients and supporting their personal views of how they want their final chapter to end rather than imposing one’s own view of that. Dr. Angell doesn’t “presume” anything but the patient’s unique right to that kind of help. Experience, in contrast to apprehension, has shown no risk to “vulnerable” people, clinically depressed or otherwise. Existing statutes and Question 2 are not about “suicide.” Statutes in Oregon, Washington, and Montana all make clear that we are talking, here, about something else. It is the patient’s diseases that is killing them. These patients seek only to modify the manner of an imminent, unavoidable death. If the distinction is not apparent to some — as it hasn’t been to many who should know better — I can recommend the the policy statement of a working group of the American Psychological Association on this matter. I quite agree with Dr. Angell that Question 2 is consistent with the true ideals of the medical profession.

  3. Deborah Golden Alecson, MS

    I was and still am a supporter of The Death With Dignity Act that did not pass in Massachusetts. I have been reading Daniel Callahan’s book, “What Kind of Life: The LImits of Medical Progress” and was surprised to learn of his position on physician-assisted suicide. His position seems incongruous to the thrust of the book which focuses on care versus cure and the responsibility of all of us to act to help those who are suffering. For some, palliative care does not ameliorate pain and suffering. Isn’t the most humane response to someone in such a circumstance who requests aid in ending their lives to do so? Is this not healing? Is this not care?

  4. david haber

    I never liked the word doctrine, but if Dr. Angell has a so-called doctrine (according to Dr. Dugdale), then I have changed my mind. I have the same one as Dr. Angell. I want to be empowered at my most vulnerable. I believe humility is a necessary part of being a physician, and if you have a different doctrine than your patient, just move out of the way.