Living -- and dying -- according to one's own desires and personal beliefs is possibly the greatest freedom a human being can have. But what happens when the autonomy and, potentially, the peace of mind of choosing one's time and place of death conflicts with qualms about a physician's role as a healer and, ultimately, the value of human life?
Massachusetts residents will contemplate those questions in November, when the Bay State will become the third in the nation to consider a ballot initiative that would allow terminally ill people to end their lives through the self-administration of medications prescribed for that purpose.
Supporters of the state's Death with Dignity Act say that it cannot truly be described as physician-assisted suicide because those drugs, under the law, cannot be administered by anyone aside from the patient for whom they are prescribed. But others allege it could seriously endanger the lives of elderly, disabled and poor people with fatal conditions, who opponents fear could be pressured by family or heirs to choose death over further medical care as a cost-control measure.
Death with Dignity: Is It Euthanasia?
Oregon became the first state, in 1994, to allow terminally ill patients to get a prescription for drugs that would hasten their death, followed by Washington state in 2008. The Massachusetts referendum is practically identical to the Washington statute, which itself was based on the Oregon law, according to Stephen Crawford, the communications director for The Massachusetts Death with Dignity Coalition.
In 2009, the Montana Supreme Court ruled that doctor-assisted suicide did not go against state laws or precedents, but there is not an official Death with Dignity law in the state.
The law does not equate to euthanasia -- or doctor-assisted suicide -- the group says, because of one important detail: The patient, who is already near death from natural causes, must be able to self-administer the drugs (usually barbiturates) that will end his or her life. While the measure permits physicians to actually prescribe the medications necessary for that act, they are not required to do so, even at a patient's request.
But opponents of the Death with Dignity Act say that it's impossible to differentiate the measure from assisted suicide, because of the assistance terminally ill people would likely need to even put their plan into action.
"Someone has to take them to the medical appointment; someone has to pick up those drugs from the pharmacy. Those drugs can be administered at home with no oversight. So is it really a voluntary act?" said Margaret Dore, a Washington-based attorney and president of Choice is an Illusion, an advocacy group that opposes Death with Dignity laws.
As written, the law contains some troubling provisions that could leave vulnerable patients open to abuse, Dore said.
The 'Slippery Slope'
Just as is stipulated in the Oregon and Washington laws, under the Massachusetts initiative patients must meet a series of requirements before they can obtain a prescription. Qualified patients must have a terminal illness with a diagnosis of six months or less to live certified by a consulting physician, who must also certify the patient is mentally competent to make and communicate their health care decisions.
Beyond that, requests for the drugs must be made twice, 15 days apart, before patients can even access them. The patient must also make a written request for the medication to his or her attending physician that is witnessed by two individuals who are not primary caregivers or family members.
While the requirements seem stringent, Dore said their failure to spell out any consequences for physicians who may violate some of the safeguards is troubling. But even more concerning to opponents is the possibility that low-income or elderly patients could face pressure from family members or even health care providers to choose death over the cost of further treatment.
"That 'slippery slope' argument has been used by the opposition for years. There's no evidence to support it," said Crawford when questioned about the likelihood of that situation.
In fact, available data from the Oregon Public Health Division indicate most patients who have taken advantage of the law were white, educated, financially stable and well-insured. It has also been used sparingly: Assisted dying has accounted for 596 deaths over 14 years; most patients were suffering from metastatic cancer with a clear prognosis of impending death.
But there has been at least one event where a patient has been directed toward suicide instead of further treatment. In 2008, Oregon resident Barbara Wagner, who suffered from terminal lung cancer, learned that her health insurance under the Oregon Health plan would not cover the cost of a $4,000-a-month medication prescribed by her doctor. But, the program did agree to cover the cost of the drugs necessary for a physician-assisted death, an event that ignited a national debate about the unavoidable conflict of interest the law opens for notoriously penny-pinching health insurance companies.
The Ambiguity of 'Self-Administer'
Supporters are legally able to differentiate between Death with Dignity and assisted suicide because qualified patients must be able to "self-administer" their life-ending drugs. That seems pretty direct -- they have to be able to physically put those drugs into their body.
It's a particularly disconcerting question for opponents, considering that, aside from cancer patients, individuals with ALS (commonly known as Lou Gehrig's disease) have been one of the primary groups choosing to die under the law. Those suffering in the late stages of the disease often lose muscle strength and coordination to the point that they cannot walk, move or even swallow.
But the phrasing of the Massachusetts law is, legally, ambiguous, according to Dore. The official ballot language says patients "may self-administer" the drugs needed to end their life, an important distinction from "must."
And while the law explicitly states that "such a process be entirely voluntary" on the part of the patient, Dore argues that "self-administer" can legally mean something as simple as being able to physically ingest the medication, not necessarily administer it in the proper sense of the word.
"Ingestion does not require a 'voluntary act,'" Dore said. "They say this is about your choice. But the way the law is written, choice is not assured."
When pressed about a possible loophole, Crawford insisted the language makes it clear that only the patient can administer the drugs.
"It must be self-administered; it's required by the law. That's the best answer I have," he said.
Majority Approve Of Law in Oregon, Washington
In the two states where Death with Dignity is legal, at least 70 percent of residents have a favorable opinion of the law, according to a 2011 poll from The National Journal and The Regence Foundation.
Massachusetts voters appear to be on the same page. Although previous attempts to legalize doctor-prescribed suicide have failed, recent polling indicates the Bay State is on its way to becoming the first on the East Coast to do so. In a new survey from Public Policy Polling, 58 percent of residents said they would vote yes on Death with Dignity, compared with 24 percent who said the opposite.