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The Bishop & The Ballot in Boston: 2012 Edition

Next month, voters in Massachusetts will decide whether to approve Question #2, "allowing a physician licensed in Massachusetts to prescribe medication, at the request of a terminally-ill patient meeting certain conditions, to end that persons life".With all the discussion here at dotCommonweal in recent weeks about whether, when and how our bishops should enter into the arena of electoral politics, the example of Cardinal Sean O'Malley of Boston and how he's chosen to engage with the challenges presented by Question #2 seems a worthy addition to our ongoing "clarification of thought". In the first in a series of columns Cardinal O'Malley is writing in the weeks leading up to the election*, three things struck me as important aspects of how he is exercising his role as bishop and teacher:Humility: O'Malley begins not by invoking his (or the pope's, or the Church's) authority, but by framing his forthcoming statements as "some reflections around the theme of end-of-life issues" that he wants "to share with the people (of) the archdiocese". He then tells the story of how as a young Franciscan, he "decided 'to make the sacrifice' in solidarity with a fellow religious" of showing up to a sparsely attended honorary degree ceremony for the then-little known Mother Teresa of Calcutta. (There's a gentle, self-mocking humor exhibited here; it's a characteristic of the cardinal's pastoral style often evident in his appearances around the archdiocese.)

Gratitude: Much of the column is simply a matter of giving recognition where recognition is due: to Eileen Egan and her longtime work with the Catholic Worker and Catholic Relief Services that led her to know---and eventually to write a biography of---Mother Teresa; to Mother Teresa herself, to Rose Hawthorne (yes, daughter of Nathaniel) who founded a Dominican community to care for those dying of cancer; to Cicely Saunders who built the world's first stand-alone hospice; to Florence Wald who popularized the hospice movement in the United States; to the "nurses and hospice workers (who) truly ministered to the whole family" when his own father was dying.Connection: O'Malley affirms that "(t)aking care of people at the end of their lives, giving palliative care to address the physical pain and bringing reassurance to people dealing with fear and frustration is truly doing something beautiful for God." He invokes the words of the Hail Mary, "Pray for us sinners, now and at the hour of our death". He recalls the popular devotion that names St. Joseph the "patron of a happy death". And he says, "We all want what is best for our loved ones, especially at the end of lifes journey."It is from that position that he moves forward to conclude, "It is my hope that this series of reflections...will demonstrate that physician assisted suicide is an assault on human dignity. It must never be seen as a viable alternative to hospice and palliative care that address not only peoples pain but also their fears and frustration."This is not (I hope!) the room for an argument about which American bishops are "better" or "worse" in this election season. (The room for an argument is, I believe, here.) Rather, I hope it's a "room" for a small part of the ongoing conversation we have about how best to read the signs of the times and, having done so, how best to preach the Gospel in the political arena.Your thoughts?*Here are links to the second and third columns published to date.

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1. We all want what is best for our loved ones, especially at the end of lifes journey.What if the wishes of "our loved ones" depart from ours? Is their end of life care for our good or theirs?2. It is my hope that this series of reflectionswill demonstrate that physician assisted suicide is an assault on human dignity. It must never be seen as a viable alternative to hospice and palliative care that address not only peoples pain but also their fears and frustration.Is forcing someone to live by norms they don't agree with an assault on their dignity? I don't mean to suggest I am a big proponent of assisted suicide, because I am not, but the notion that it is incompatible with a value known as "human dignity" depends quite a bit how one defines dignity. When I read the word "dignity" I take it as a stand in for "what my values tell me I and people I love should want" without being willing to admit that these values are not universal. It's a shortcut that often bypasses logic and reasonable rejoinders. There are reasons to oppose or at least be very, very cautious regarding the practice of physician assisted suicide but the preservation of something called "human dignity" isn't one of them unless your notion of human dignity is devoid of the concept of autonomy or self-determination.

There is some confusion produced by conflating assisted suicide with stopping active treatment measures . Bill Keller in today's NYT has an article about his fathrer-in-law's last days at a hospital in London in which active treatment was stopped. He died quietly with his family by his side and without the clamor of beeping machines,IV's and q2r vital sign checking. Many of the comments showed that people did not grasp the difference between shooting the patient up with a massive dose of morphine and just stopping treatment when there was no hope of recovery. When a person is clearly close to the end of their journey, doing everything medically possible is often not in their best interests. Palliative care and comfort measures are more humane, more gentle, and less traumatic for the terminally ill. Hospice care at a center or at home is supportive of the patient and the family and certainly fits the dying with dignity model. I had been in nursing for many years and from that experience if I had the choice, I would not want to come to the end of my life hooked up to IV's, monitors, feeding tubes, etc.

When I read the word dignity I take it as a stand in for what my values tell me I and people I love should want without being willing to admit that these values are not universal. Its a shortcut that often bypasses logic and reasonable rejoinders.I have never even gotten this much out of appeals to human dignity, so I am glad to have it clarified a little further. I really don't think it means much more than this.

Barbara: When you wrote, "When I read the word dignity I take it as a stand in for what my values tell me I and people I love should want without being willing to admit that these values are not universal," did you mean "that these values are not universally shared"? One could argue that the values are universal--apply to all human beings--without their being universally shared.I agree that human dignity has to include the notions of self-determination or autonomy. See Aquinas: Super Epistolam ad Romanos Lectura, ch. II, lect. 3 (Marietti #217): Et iste est supremus gradus dignitatis in hominibus, ut scilicet non ab aliis, sed a seipsis inducantur ad bonum. (This is the supreme degree of dignity in human beings, that they be led to the good by themselves and not by others.")

Are not universally shared. Yes. People disagree about them, and especially, disagree about how to strike a balance when they come in conflict as they might in end of life scenarios.

These are awkward questions, and roughly speaking the same issue is going on in Vermont, where I live. I imagine it will pass the legislature, though apparently the local medical society opposes it. Two or three years ago I prepared an advanced directive that lists, among other things, the various conditions under which I do not want my life prolonged. This last is an effort to avoid dying while plugged into a battery of beeping machines which ultimately do no good. At the same time I also say that I am not in favor of assisted suicide, under whatever name if travels (euthanasia, death with dignity, etc. etc.) At the same time, I've also stated I'm not in favor of pain, and want whatever palliative care is available.All the same, I know it's very difficult to decide what's right and what's not in such a case, since each case really is, or can be, unique and not foreseeable. At the same time, the more I read and hear about the ballooning of the health care budgets, both state and federal, the more I worry that the temptation will arise to hurry people into death, not so much out of a desire for mercy or dignity, perhaps, as a desire to save the bottom line. And that's an interest both of private insurance companies, and public health services, both keeping an eye on budgets. Perhaps this is an unreal nightmare, and I hope it is. But as the historians have told us, in Germany, the precursor to the Holocaust, and doing away with people on grounds of "race," was doing away with them, already by the late 1930s, because of old age, illness, mental problems, etc., all of which made them supposedly useless (and expensive) members of society.

physician assisted suicide is an assault on human dignityIt seems to me that in this context, human dignity means respect for the individual's life. No one has the right to kill - thou shalt not kill - or take their own life. The assault on their dignity is the assault on their life. And such a claim is directly supportable by logic. While these claims may not be universally held, that doesnt detract from their validity or Truth. In fact, you cannot respect life and want to end it at the same time, that is completely illogical.

It seems to me that in this context, human dignity means respect for the individuals life. No one has the right to kill thou shalt not kill or take their own life.Bruce,If human dignity really means respect for the individual's life, why not just say respect for the individual's life?Here is the footnote from the NAB for Exodus 20:13, "You shall not kill."

Kill: as frequent instances of killing in the context of war or certain crimes (see vv. 1218) demonstrate in the Old Testament, not all killing comes within the scope of the commandment. For this reason, the Hebrew verb translated here as kill is often understood as murder, although it is in fact used in the Old Testament at times for unintentional acts of killing (e.g., Dt 4:41; Jos 20:3) and for legally sanctioned killing (Nm 35:30). The term may originally have designated any killing of another Israelite, including acts of manslaughter, for which the victims kin could exact vengeance. In the present context, it denotes the killing of one Israelite by another, motivated by hatred or the like (Nm 35:20; cf. Hos 6:9).

This commandment obviously doesn't forbid all killing, and I don't think it can be stretched to include suicide. It has always seemed to me that we read things back into the Ten Commandments that clearly weren't intended, and then we invest them with tremendous authority because God handed them down "personally." Judaism (this is based on some very quick research) seems to prohibit suicide (and assisted suicide), but not based on the prohibition against killing. In fact, you cannot respect life and want to end it at the same time, that is completely illogical.As in, say, executing someone who committed murder?

Those whom I have talked to about what happens at the end of life all emphasize the many and unforseeable variables that complicate the carrying out of the patient's wishes. I'm sure there are many who know more about this than I, but it seems to me that back in 2005, at the time of John Paul II's death, all sorts of measures were being taken to prolong his life, though not to cure his ailments, which were mostly those of old age. Of course I have no idea what instructions, if any, he had given on this subject, and no doubt towards the end such decisions were in the hands of others, as is true in many deathbed cases. But I do remember some people saying that his end was unnecessarily and painfully prolonged, and that it was a shame (to use no stronger word) that he could not be allowed to slip peacefully out, rather as if he had been in the kind of hospice situation that Holloway describes above. It would have been perhaps not only easier for him, but also would have given the world something of a model of a Christian death in an age when the medical profession can use all sorts of new techniques to postpone natural death. If you haven't yet read it, see Jerome Groopman's long review of Victoria Sweet's new book "God's Hotel," in the 27 Sept. New York Review of Books. Though the book isn't about the end of life, it's about the dignified and humane treatment of patients who, perhaps because they come from the bottom ranks of society, are not the targets of Big Medicine and Big Pharma. (I'm afraid it needs a subscription to read on line).

Nickolas C. says "Perhaps this is an unreal nightmare,' not so.. we all will live it.... The prevalence of Alzheimer's in the USA, 5 million now and growing, will effect all families soon [mine already]. This is just one disease that we oldsters face. We need to stand up for dignity, dignity, dignity. I appreciate Cardinal O'Malley's approach to confront this insidious initiative.

I should add.. want to know the Christian stance?... try the Franciscan stance first and don't look for another.

I think it's important to understand that these "insidious initiatives" are often promulgated by very frightened people.My mother and dad were very chary of hospice when Dad was dying because they were afraid Christians had "infiltrated" it to use as a way to get converts and keep people alive as long as possible regardless of pain and expense, and it took a lot of coaxing for them to even talk with someone.And it's true that a couple of the first few caregivers (they usually rotate people at the beginning to see whom the family "clicks" with) introduced themselves with the words, "I'm Bill and I'm a Christian," to which Dad replied, "I'm a Unitarian, and I want another nurse."The nurse who eventually took the lead on Dad's case was a wonderful woman, a practicing Catholic, who was very clear about what hospice could and could not do, and answered the hard questions (usually some form of "how long have I got and how much will it hurt?") very candidly. Both my parents grew very fond of her during the year Dad was on hospice.Toward the end, my mother became extremely agitated and asked for the nurse to administer an overdose of something. Dad was getting ATC pain killers, and was very peaceful, but a death-watch is awfully hard for some peoplem and there's a weird combination of boredom and anxiety that sets in from grief and sleep-deprivation. For someone in her 80s, that's pretty difficult.I think that end-of-life care could also include a component for frazzled caregivers. I was there full-time for the last two weeks, but was never able to get my mother to get any rest, and, in the end, I think she needed as much comfort care as Dad.

Jean, I am interested to know why (or maybe if) these nurses felt compelled to share their religious views -- this did not happen when my father or either of my in laws were in hospice care. It strikes me as inappropriate for a professional to introduce themselves in that way although I can imagine the topic might come up as people get to know each other.

Barbara, there had been a spate of letters in my parents' local paper about a nurse on hospice who refused to administer some type of care to a man in his last hours on religious grounds, so they were on the lookout for "religious nuts."I have no idea why Bill introduced himself that way. Perhaps it reassures some patients. As far as Mother and Dad were concerned, "I'm a Christian" was code for "I'll withhold pain meds so you can suffer for Jesus."