Massachusetts ballot questions: marijuana, assisted suicide

I received a letter from a reader (OK, my sister, but she’s a reader) asking me to weigh in on a couple of Massachusetts ballot initiatives. I normally wouldn’t care what’s happening in Mass, but these questions touch on important medical ethics and policy issues that I’ve addressed before.

Medical Use of Marijuana

Ballot Question 3:

A YES VOTE would enact the proposed law eliminating state criminal and civil penalties related to the medical use of marijuana, allowing patients meeting certain conditions to obtain marijuana produced and distributed by new state-regulated centers or, in specific hardship cases, to grow marijuana for their own use.

A NO VOTE would make no change in existing laws.

Many states are struggling with this question. Marijuana is considered by many Americans to be a relatively harmless drug, one whose criminalization is controversial. But the question is not whether to decriminalize cannabis but whether it should be made legal (under state law) for medical use.

States don’t have any say in the classification of controlled substances. The federal government has classified cannabis as a substance with no legitimate uses, and federal laws can be used to enforce this. The fight for legalization is a national rather than local issue, so we’ll address the question as if this weren’t a problem.

Cannabis has been studied for a number of medical uses. The proposed ballot question would allow certification of patients with a serious medical condition, and a number of specific conditions are named.

Here’s the problem: cannabis has never been consistently found to help with any medical problem (this blog has many entries on the topic). In deciding how to vote, there are a few things to consider.

  • If you believe criminalization is wrong, and you don’t care how we get around it, you could vote “yes”. Some might find this too cynical and would prefer “real” decriminalization.
  • If you think sick people should be able to get high without fear of prosecution, and the medical evidence isn’t that important to you, you can vote “yes”.
  • If you think doctors are really the best gatekeepers for the legal use of marijuana you could vote “yes”.

We have a very similar law in my state and I find it very problematic; I don’t think doctors should be involved in deciding who does or doesn’t get to use a recreational drug.  If and when cannabis is found to be significantly more useful than other medications, the right thing to do would be to change its DEA schedule to reflect its place in our pharmacopoeia.

Physician-assisted death

Question 2:

A YES VOTE would enact the proposed law allowing a physician licensed in Massachusetts to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that person’s life.

A NO VOTE would make no change in existing laws.

My personal bias is that doctors should not be in the killing business, even if they think they are doing it for the right reason. Doctors who participate in executions often have what they consider good motives, as do those participating in assisted-suicide, but it is very difficult to separate out a physician’s feelings to create an “objective” assessment.  There is, necessarily, no objective way to judge whether someone’s suicide would be a “good act”.  This bill doesn’t really ask that but assumes that an autonomous patient making a decision about their own death should have the right to have a doctor help them.

The law fails to require any sort of psychological evaluation, fails to involve a palliative care or hospice evaluation, and gives no objective criteria as to what illnesses are likely to qualify. As someone who deals with death and dying daily, I can honestly state that it is very hard to determine if someone is going to die within six months of an incurable or irreversible disease. I can say that a good palliative care physician can create a reasonable amount of comfort for most, but not all, patients near the end of life. And the principle of dual effect states that if a medication given to relieve suffering happens to hasten death, this is not an ethical breach (although there’s a bit of controversy surrounding this).

You should consider voting yes for the following reasons:

  • You feel that patient autonomy trumps all other values
  • You feel that a doctor should be allowed to effectively make the decision to kill a patient

For a doctor to be given the power to intentionally kill someone, even with their consent, is not something you should be comfortable with.  If I were a Massachusetts resident I would vote “no”.  As a doctor, I don’t want that kind of power.

 

16 Comments

  1. D. Lane

     /  October 22, 2012

    If doctors don’t want to be in the “killing business,” there needs to be some other legal way for the terminally ill to gain access to the requisite drugs.
    And there would still need to be a medical process, as determining whether or not someone is terminally ill with less than six months to live would necessitate medical input.

    I see no issue in doctors prescribing life-ending medications as long as patients are required to take them without assistance – in other words, the person is the direct cause of his/her own death. Some would argue that the illness causes the death, with the drugs being used only to hasten the inevitable and ensure that suffering is minimized to the greatest extent possible.

  2. D. C. Sessions

     /  October 22, 2012

    Rather close to home, here — my mother died this summer. Good hospice care, the lung cancer wasn’t causing her any real problems until the last couple of months and no particular pain until the last two weeks.

    Which is where the hospice care came in — one week of inpatient, all the pain control she wanted — and if it led to respiratory issues, well, it was lung cancer, after all. I was out of state at the time (or barely in-state, driving back) but although at some point I’ll read the details, they really don’t matter except that she wasn’t suffering much or for long.

    As for assistance — well, when my time comes and assuming I still have enough control to work the valves I don’t need a prescription for nitrogen or any number of other common industrial materials. That’s engineers for you.

  3. Old Geezer

     /  October 22, 2012

    I would like to respectfully disagree with you in two respects. First, doctors do, quite regularly “intentionally kill someone….” The family is brought into the room. They are told that there is no hope for recovery, the bodily functions are being maintained by the various machines that are flashing and beeping and nothing can be done. After kind, considerate counsel, the machines are turned off and the patient is “allowed” to pass away. Had the machines been left turned on, the body would continue to make a charade of life for (perhaps) years more. A decision between sentient beings, participated in by the doctor, changed what could be described as a living person into a dead person. That is a normal part of the practice of medicine. There are some other messy issues involved in the implementation of this proposed law, but the fundamentals are simply a doctor and another individual consult together to decide whether an individual continues to live.

    My second issue is with the concept of “…I will do no harm….” I can clearly understand how your years of training and practice – all generally focused on restoring health and alleviating pain – would find the taking of life to be antithetical to the concept of I will do no harm. That said, I have spent a lot of time working in hospice. Not all of those we served in a hospice setting benefited simply from palliative care and counseling. As I am sure you are aware, just because one is diagnosed as being terminal and expected to die within six months, that does not mean that that is what will happen. One man I worked with was deeply embittered because he had stuck around for over 18 months and all he wanted to do was be reunited with his late wife. He hurt physically, emotionally and spiritually and nothing would give him peace. Every day he asked us to put him out of his misery and every day we (obviously) could not. Prolonging his suffering simply did not fit into my definition of “I will do no harm” but I didn’t and don’t have any simple answer for what does.

  4. I would consider respecting a person’s living will or family’s request to remove them from life support, akin to giving a physician the responsibility of killing a person, only the method for doing so is pretty inhumane. I would certainly offer my pets a less traumatic end than starving or suffocating to death.

    I live in Oregon where physician assisted suicide is legal. The physician is not the one to administer the medication to end the patient’s life. He or she only prescribes the medication. There are rules in place to ensure the patient is not being coerced. There is some good information on the wiki page about it and its impact http://en.wikipedia.org/wiki/Oregon_Death_with_Dignity_Act

    Obviously, how a law might be enacted in MA, could be totally different and may not protect the patient as well, but simply offering terminally ill patients who are in pain, an option to end their life with as little suffering as possible, seems like an emotionally difficult but valid part of a physician’s responsibility. The concerns you have about psychological evaluation and other aspects of the law itself, are valid, but I reject the idea that a doctor shouldn’t be asked to provide a means of allowing someone to end their life when there is no hope for recovery.

  5. Another question is how easy it is to get medical cannibas. It’s very easy in California. (This is no different than how pediatricians who refuse to treat unvaccinated children end with the antivaxer parents leaving. There are a lot of doctors out there, and only the naive would expect all of them to be completely ethical.)

    Assisted suicide is something that should never happen. Every realistic scenario in my mind ends in a pretty nasty abuse of it.

    • D. C. Sessions

       /  October 23, 2012

      Assisted suicide is something that should never happen. Every realistic scenario in my mind ends in a pretty nasty abuse of it.

      Well, it’s been the law in Oregon for quite a while now. Do you think that it’s been long enough to test your expectations?

  6. Reblogged this on PNVP.Org | Peace & Non-Violence Project and commented:
    But the question is not whether to decriminalize cannabis but whether it should be made legal (under state law) for medical use.

  7. DJMH

     /  October 24, 2012

    “I don’t think doctors should be involved in deciding who does or doesn’t get to use a recreational drug. ”

    You mean, like Vicodin?

  8. Barbarella

     /  October 27, 2012

    Sorry, doctor, I do believe personal autonomy trumps all. In some cases, the choice of whether to end a life is simple mercy. And doctors have a tremendous political power in the form of the AMA. I have never owned an animal and, in its last moments or days of life, tied it down and left it screaming until ‘natural’ death occurred. I play God with them when I rescue them off the street, decide whether they can keep their reproductive organs (they can’t) and whether they have medical care (they do). It may not be right or natural, but I take the responsibility for them. It is my choice to do so.

    • You misunderstand the nature of patient autonomy. Autonomy does not mean forcing your doctor to do whatever you want.

  9. This does not present facts supporting both sides. This is an editorial. Who cares what this person thinks……back to real research….what a waste of time.

    • Old Geezer

       /  October 27, 2012

      And yet, with time being so precious to you, you stepped away from your research long enough to bless us with your comment. I, for one, am greatly enriched.

  10. Isabel

     /  October 30, 2012

    “If and when cannabis is found to be significantly more useful than other medications”

    Why does it have to be “significantly more useful ” than other medications? Why not just useful” Or with less side effects, or more tolerated by specific individual patients?

    And you are ignoring a mountain of research. But don’t ask me to go find it for you.You know where to look. Seriously, how big of an asshole does a person have to be to refuse someone their medication because the Feds banned it long ago for reasons that have nothing to do with health risks (that was a rationalization that came later) and accuse them all of just wanting to get high?

    • Seriously, how big of an asshole does a person have to be to refuse someone their medication because the Feds banned it long ago…

      That’s a different question altogether. And it doesn’t make a lot of sense, internally. What do you mean by ‘refuse someone meds…the Feds banned?” That sentence makes it sound like a dealer is refusing to distribute pot because it’s against the law. Is that what you meant? Because doctors aren’t supposed to sell illegal drugs, and if they do, they are subject to prosecution.

      • Isabel

         /  November 1, 2012

        Why don’t you answer my question? Why wouldn’t you support rescheduling unless it is “significantly more useful ” than other medications? And didn’t that just get a hearing? Does anyone know if it was rescheduled last week? (it shouldn’t be scheduled in the first place imo)

        As far as my other rhetorical question, people who want it to relieve illness can’t get it because people like you hold it to a higher standard than other meds. Even “recreational” (I really hate that term) use is held to a higher standard than alcohol in your world, as we saw in your previous posts and tweets. Any mention of enjoying the effects is condemned with a moralistic demand that side effects be listed every time someone mentions it. Who does that with alcohol??

        You are also obsessed with the smoking issue, but if you live in the city or your neighbor has a wood stove, you inhale more particulates than someone like me who smokes a few tokes now and then.

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