Kelly Lange doesn’t want to die, but she knows she’s going to, and earlier in her life than most.
She was diagnosed with breast cancer in 1995, at the age of 32. For eight years her disease responded well enough to drugs, but in 2003, the doctors found the cancer had metastasized—average prognosis: two to three years. She joined a metastatic breast cancer support group in Annapolis, where she lives, and over the last 12 years, her cancer has responded well to just a single drug therapy, which means she’s lived to see many women join the group, decline, and die. And so, despite her own luck, Lange has no illusions about metastatic breast cancer’s inevitable course, and neither do the women in her group. “There are some certainties in cancer,” she said. “When it gets to this stage it doesn’t go away. You don’t just have these miraculous recoveries.”
Her support group doesn’t talk about politics, broadly, or even Maryland’s consideration of death with dignity legislation, specifically. It’s not legislative squabbles that interest them. The women talk about wanting another end-of-life option, and legalizing physician aid in dying offers them that.
“It’s not that I want to die,” Lange said. “It’s that I want to control my own suffering.”
In 2015, for the first time, Maryland’s legislature began considering a death with dignity bill, which would make it legal for physicians to help patients with a terminal prognosis of six months or less to end their lives. After two public hearings—one before the state’s House of Delegates, another before the Senate—the legislation was tabled for the remainder of the session. But after some tweaking, the bill’s sponsors say it will be back in the next session in January.
If passed, Maryland’s death with dignity law would look much like Oregon’s. Three separate requests by the patient—first oral, then written, then oral again—would be required. Two witnesses would have to sign the written request, and at least one couldn’t be a relative or someone who will benefit financially from the patient’s death. Anyone who chooses to use the law would be marked as having died of natural causes, protecting life insurance policies.
In her work as a patient advocate, Lange is intimately exposed to death in all its forms and progressions. She says she feels a sense of responsibility to the women she’s watched die and to the people “actively dying” who are too sick to come testify. On breast cancer, Lange is a public advocate, but on death with dignity she speaks as a private citizen who’s made it her business to openly and avidly support the legislative effort in Maryland.
As of July, three states have enacted death with dignity laws—Oregon, Washington, and Vermont—and courts in Montana and New Mexico have ruled that physician aid in dying is legal. Maryland is one of 24 states that began considering death with dignity legislation this year, compared to just one—New Jersey—in 2014. Advocates and opponents alike credit the public decline and death of Brittany Maynard, a terminally ill brain cancer patient whose move to Oregon drew national attention, with the sea change in legislative and media attention.
The medications most often given to patients wishing to die are Seconal and Nembutal. Just like allergy and blood pressure prescriptions in states where death with dignity is legal, local pharmacies dispense the fatal dose of barbiturates. Dying isn’t as easy as taking one or two pills: To prepare the dose, a number of capsules are opened and the contents are dumped into a glass. After pouring in a liquid, like water or juice, the drink is stirred. Depending on the person, death can occur in less than ten minutes or take hours. The person slips into unconsciousness, respiration slows, and death soon follows.
Because morphine is used for palliative care—in which the primary goal is comfort—it is generally easier for terminally ill patients in hospice to access larger quantities of morphine than barbiturates in states where death with dignity is not legal.
Lange and the members of her Annapolis-based support group are realists. “We talk a lot about hospice care, and how, ‘don’t worry they can always give you a lot of morphine,’” she said. “We talk in a practical sense about what the options are. It’s a kind of a sad situation that it’s a wink-wink, nod-nod that they’re going to overdose you on morphine.”
That kind of overdosing sounds a bit like assisted suicide, which is a felony in some states. But in 1997, the U.S. Supreme Court reaffirmed “the double effect doctrine,” protecting doctors whose intent it is to help a patient—whether by administering palliative pain relief, operating, or by some other means—from prosecution, if the doctor’s action causes the unintended “double effect” of ending the patient’s life. Intent is the key, and intent is hard to prove. The doctrine offers physicians who allow terminal patients to overdose a defense.
In 1999, two years after that Supreme Court ruling, Maryland made assisted suicide a felony, punishable by up to one year in jail, a fine of up to $10,000, or both. That law is the reason Alex Fraser died alone.
On June 6, 2014, Fraser tried to overdose on Percocet, without success; he then tried to slit his wrists, but his Parkinson’s tremor made it impossible. His attempts to die continued into the next day when he managed to hold a gun steadily enough to shoot himself in the head. He was 90.
Fraser had lived a full and vibrant life, the Washington Post eulogized: He founded Open University, where adults could take short-term classes, like “Parrot Psychology.” His D.C. license plate read, “ENJOY.”
He knew the way he wanted to live, his oldest daughter Alexa Fraser said, and immobile and incapacitated from advanced Parkinson’s was not it. He ended his life alone to protect his family from legal complicity. He had instilled in his children that physician aid in dying should be a right. It was “the familial message,” said Alexa Fraser.
The elder Fraser also had been a member of the Hemlock Society, which, in 2005, was absorbed by Compassion & Choices. Shortly after his death, Alexa contacted the organization. She was ready to go out and do whatever work they gave her, and a few weeks later, the advocacy group called asking Alexa to tell her father’s story on WAMU’s The Diane Rehm Show. The episode aired July 7, 2014, a month to the day after her father died.
McShane Glover has known Richard E. “Dick” Israel since she was a child. He was a friend of her father’s. Israel has had a distinguished career in Maryland government, including serving 25 years as an assistant attorney general and eight years as an Annapolis alderman. Glover served on Israel’s first political campaign, when he ran for alderman in 2005, and the two became good friends. Five years ago, they began talking about his death.
Israel was diagnosed with Parkinson’s in 1999, and for 14 years he insisted on living independently in his two-story townhouse in Annapolis’ First Ward. As his disease progressed, friends and dedicated caregivers, including Glover, worried he would suffer a bad fall at home.
One day in early 2013, Israel didn’t show up for a meeting at City Hall. Colleagues contacted his friends, who went over to Israel’s house and found he had fallen and couldn’t call for help. No longer able to live alone, Israel made plans to move into Ginger Cove, an assisted living facility just outside of Annapolis. In April 2013, he resigned his position as alderman, and in May, he moved.
Over the past couple years, Israel’s Parkinson’s has rapidly degenerated his body. His mind is sharp as ever, but Israel communicates now mainly by tapping out words, letter by letter, on a piece of paper that displays the alphabet. As one of his dedicated caregivers, Glover is intimately familiar with the course of Israel’s Parkinson’s and his wishes. In December 2014, Glover approached a legislator named Shane Pendergrass and pitched the idea of right-to-die legislation. After that, the process moved quickly.
When Glover asked Israel to lend his name to the bill he resisted. The legislation was for all Marylanders, not him in particular, and moreover, it was the legislation’s substance that mattered. But without a public face, Glover said, the bill wouldn’t get the attention it deserved. A little reluctantly—he was never a man to take the spotlight—Israel agreed.
In March 2015, during the legislature’s public hearing on death with dignity, Glover read Israel’s statement: “I can appreciate the irony that if my advocacy is successful and I choose the ‘exit strategy’ that allows a ‘push’ of nature, my voice will be forever stilled. So be it.”
On Feb. 13, 2015, both houses in Maryland’s General Assembly introduced the Richard E. “Dick” Israel and Roger “Pip” Moyer Death With Dignity Act. Moyer, the other namesake of the bill, was a former mayor of Annapolis. He died on Jan. 10, 2015 at 80, two decades after being diagnosed with Parkinson’s. (Israel died on July 20.)
Sen. Ron Young, who introduced the bill, opened the Senate hearing on March 10. The Judicial Proceedings Committee asked questions of the first few speakers that ranged from the philosophical to the semantic. One senator quibbled with the word “dignity” in the bill’s title and another suggested changing it to something like “death with liberty” or “death with autonomy.”
And then there was Sen. Bob Cassilly. After Young completed his testimony, Cassilly stated: “I personally have gained very much from seeing people suffer through death. It’s made me a much stronger person. Knowing that people fought for the last few seconds of their life, to hang onto their life makes me all the more appreciative and sometimes the more courageous to deal with difficulties in my own life or other people’s lives.”
It wasn’t a line of reasoning Cassilly easily let go. A little while later, Stephen Sachs, who served as Maryland’s attorney general in the late-1970s and ’80s, testified about having talked with Israel. Cassilly asked again, this time with a little more kick: “Does that occur to you at all? That if this guy had punched out a couple months ago that there’s a lot of thinking and living and knowledge that those around him would not have gleaned from his dying.”
Sachs was unflinching in his response. “I don’t think Dick Israel should be going through what he’s going through in order for me to be moved. He is not there for my benefit. He, not I, is the one who should make that judgment, and I don’t mean to trivialize what you said, but it’s not for our entertainment.”
The first round of proponents wrapped up, and the committee turned to the opposition. Their second person to testify was O.J. Brigance, a former Baltimore Ravens linebacker and an outspoken opponent of death with dignity. In 1997, Brigance was diagnosed with amyotrophic lateral sclerosis or Lou Gehrig’s disease. Most people live from three to five years after being diagnosed. Today, eight years after learning of his ALS, Brigance uses a wheelchair and speaks through a computer, like Stephen Hawking. Both men have lived longer than they could have without modern medical technology—Hawking for a remarkable five decades.
“The thought that there would be a legal avenue for an individual to take his or her own life in a moment of despair, robbing friends, friends, and society of their contribution to society saddens me, and is a tragedy,” Brigance testified. “Every second of life is God-given.”
It’s one of the cold realities of the 21st century that medical technology contributes to the belief that we can prevent or cure any ailment, and even stave off death. It’s the same advanced medical technology that keeps alive people who otherwise would have died a natural death—even if they wish to die. The will to live is strong, but will is not an antidote to death. At some point the end will come, and when it does, proponents of the bill say, the dying must be able to choose for him or herself.
Fraser feels great empathy for Brigance, but his testimony angered her: “If it’s not for you, you don’t act… But don’t tell me what day I can choose.”
A little while after Brigance testified, Kelly Lange’s turn came. The previous week, she had waited through hearings in the House, glued to a bench all day for fear of missing her turn. Now before the Senate, she strode to the podium to speak about her work as both a patient and an advocate.
“I’ve seen a lot of [people] die, and sometimes it’s been pretty darn awful,” Lange said, relating how cancer metastasizes and destroys a body. She’s on her fourth round of targeted therapy now, and she knows what’s in her future. Eventually, the medicine will fail.
“I don’t want my death to be character building for someone. I want to be in control in a legal way. I want to hold my husband’s hand and be with my family, and not take my life with a shotgun or have my hospice team over-medicate me with morphine. It’s very important to those of us with advanced cancer that you give us this option,” Lange said.
“We are dying in pain, and we want control over our end.”
As she finished, people listening in the hall clapped, a first in a day full of testimony.
Nationally, 70 percent of Americans support legalizing aid in dying, according to a 2014 Gallup poll. In Maryland, 60 percent of the public supports policy that would allow physicians to prescribe terminally ill patients, whose prognosis is less than six months, a fatal dosage of medication, according to a Goucher Poll conducted in February 2015. Thirty-five percent of Marylanders oppose the policy.
The split doesn’t fall along party lines. The most significant demographic divide is a relatively strong indirect correlation between church attendance and support. Eighty percent of people who rarely or never attend church support the bill, while only 37 percent of people who attend church once or more a week support it.
About a third of the current Maryland legislature is composed of freshmen. And though a majority of Americans support legalizing aid in dying, Pendergrass guessed that her death with dignity bill was too controversial for most new legislators, particularly before they’d had a chance to go home and talk with their constituents.
Come next session, she will introduce an updated version of the bill. But Pendergrass noted that just because there might be changes, the opposition won’t just melt away.
“There is no fix to satisfy people [who are] in favor of taking away the right of self determination from dying people, beyond killing the bill,” she says.
As more states consider right-to-die legislation and more Brittany Maynard’s tell their stories, the face of the movement will change. Maynard was a big first step. She was young and she spoke with a clear voice. Her eyes sparkled and her skin glowed, but still, she was dying. She was emotional but also level-headed about death. She didn’t want to die, but she knew she was going to, and she wanted to control her suffering.
At 52, Kelly Lange doesn’t look ill, but the cancer’s there, and slowly it’ll learn how to survive her current therapy. She has a few treatment options once it does, and she wants very much to live, but she knows that eventually her time will run out.
“I think the time is right,” she said of the legislation. “People are becoming more open-minded, that the choices other people make aren’t as scary… I don’t know if I would use it or not, because I don’t know what [dying] is going to be like.”