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How to Die in Massachusetts

For one thing, opponents outspent supporters by over four to one—$5,451,404.97 to $1,121,921.75, according to the state’s Office of Campaign and Political Finance—and much of that money was spent in the last month of the campaign. The money came mainly from Catholic institutions, both within the state and from dioceses throughout the country, most of it funneled through an organization called the Committee Against Physician-Assisted Suicide. For example, the Boston Catholic Television Center and St. John’s Seminary each contributed $1 million. After the election, Cardinal O’Malley publicly thanked his fellow bishops and Catholic organizations for their help in defeating the DWDA, and was named chairman of the US Conference of Catholic Bishops’ Pro-Life Committee.

In addition, a right-wing organization based in Mississippi, called the American Family Association, contributed $250,000 to the Committee Against Physician-Assisted Suicide, but when its extreme anti-gay views were revealed in the press, the money was returned. Another conservative group, the American Principles Project, headquartered in Washington, D.C., and its chairman of the board donated a total of $673,000 to two opposition groups.

On the other side, support for the initiative came mainly through the efforts of two organizations, Dignity 2012 and Compassion & Choices, a national advocacy group with headquarters in Denver. Both relied mainly on individual donations, which were much less than needed or anticipated.

Opponents mounted a barrage of TV ads in the last month, overseen by Joseph Baerlein of Rasky Baerlein Strategic Communications, who boasts a perfect record in ballot campaigns and called this his toughest fight. These ads were enormously successful in raising doubts among people who initially favored the DWDA. The most effective showed a “pharmacist” grimly pouring hundreds of red capsules into a dish, and lamenting that he was now required to help people to die. People could simply pick up the drugs, he said, and kill themselves, “no doctors, no hospitals, just a hundred of these.” While the ad was misleading (the medication could be dissolved in liquid, so no one would have to swallow a hundred capsules), it raised the specter of terminally ill patients, without any oversight, picking up a lethal medication and dying alone. By taking one of the virtues of the DWDA—the fact that death usually occurs at home and patients can decide whom they want with them—and standing it on its head, this ad played to the common fear people have of being abandoned while they die.

A second reason for the late reversal was the paradoxical effect of the enormously successful campaign to elect Elizabeth Warren. Supporters of the DWDA assumed that they could ride her coattails, in the sense that liberals who voted for her would also be likely to vote for the DWDA. Although that was true of relatively well-educated and affluent white liberals, it turned out not to be true of working-class white liberals or of Latino and black voters. Warren’s ground campaign led to a record turnout of Democratic voters, more even than in the 2008 election, but the urban working-class and minority communities that overwhelmingly supported her were exactly where opposition to the DWDA was greatest. Probably this reflected greater religiosity in working-class communities and perhaps a distrust of doctors among minorities. Whatever the reasons, it came as a surprise to supporters of the DWDA. In addition, Warren’s huge success in raising money from affluent liberals in Massachusetts probably hurt fund-raising efforts for the DWDA, since likely donors may have felt tapped out.

Several newspapers supported the DWDA, notably the Quincy Patriot Ledger, The Berkshire Eagle, and The MetroWest Daily News. But the largest and most important newspaper in Massachusetts, The Boston Globe, opposed it. In an oddly incoherent editorial, it said that as long as some dying patients receive inadequate end-of-life care, they should not be given the choice of hastening their death. The assertion that good end-of-life care is not available to all terminally ill patients is no doubt true, although the editorial offered no evidence. But it makes no sense to hold dying patients hostage to the defects in our health care system by denying them the choice of ending their lives more peacefully—a choice that they might want all the more because of poor palliative care.

Moreover, the experience in Oregon showed that end-of-life care improved after passage of that state’s DWDA, not before. Still, The Boston Globe editorial hurt the chances of passing the DWDA, since many voters don’t familiarize themselves with ballot referendums, but simply take editorials with them into the polling booth and follow their recommendations.

Despite the powerful and well-heeled opposition, the vote was very close, and the issue will not go away. Most people know someone who has died a miserable, protracted death from an incurable illness, and they fear that for themselves. Although it is not possible to put the DWDA on the Massachusetts ballot again for another six years, there will probably be similar initiatives in other states, and also efforts to accomplish the same thing through state legislatures and the courts (the latter was a successful strategy in Montana).

Before the discovery of antibiotics, the lives of cancer patients were often cut off by pneumonia or other infections. But now most cancer patients die in hospitals after a prolonged period of suffering. Good palliative care can alleviate most suffering, but not all. Pain is usually easier to relieve than many other kinds of suffering, such as weakness, loss of bodily functions, shortness of breath, and nausea. Moreover, sometimes the side effects of drugs used to palliate suffering are not acceptable to the patient, as was true in my father’s case. When suffering is extreme and can’t be adequately relieved, doctors often hasten death by administering large doses of opioids, or sedating patients to the point of unconsciousness and allowing them to die of dehydration.

Death that results from these measures is sometimes claimed to be the unintended consequence of efforts to relieve suffering, although it’s hard to imagine that anyone genuinely believes that death from dehydration is unintended. Still, to circumvent laws against euthanasia, these practices occur more or less underground, mainly in hospitals, and often without the express consent of the patient. The DWDA has the advantage of bringing assisted dying into the open, regulating it, and, most important, putting patients in charge.

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