Affirming a right to die
SAN DIEGO -- Brittany Maynard was soon to die. The question was whether she could do so on her own terms, as a last act of autonomy. Dr. Lynette Cederquist, who regrets that Maynard had to move to Oregon in order to do so, is working with others to change California law to allow physician assistance in dying.
Maynard, a 29-year-old newlywed, knew that her brain cancer would fill her final months with excruciating headaches, seizures, paralysis, loss of eyesight and the ability to speak. Radiation and chemotherapy would have purchased mere months. “I’m not killing myself,” she said. “Cancer is killing me.” She would not put her loved ones through her cancer’s depredations.
Advances in public health and medical capabilities for prolonging life -- and dying -- intensify interest in end-of-life issues. Reductions in heart disease and stroke have increased the number of people living to experience decrepitude’s encroachments, including dementia.
“Dementia,” Cederquist says, “is a whole different dilemma.” Assisted suicide perhaps should be allowed only when survival is estimated at six months or less, but at that time persons suffering dementia have lost decisional capacity.
Physician-assisted dying has been done surreptitiously “as long as we have been practicing medicine,” says Cederquist, professor of internal medicine at the University of California, San Diego. Today, even in the 46 states without physician-assisted dying, doctors may legally offer “terminal sedation” -- say, a life-shortening dose of morphine -- when intense physical suffering cannot otherwise be satisfactorily alleviated. Some Catholic and other ethicists endorse a “double effect” standard: If the intent is to alleviate suffering but a consequence is death, the intent justifies the act.
Cederquist says the most common reason for requesting assistance in dying is not “intolerable physical suffering.” Rather, it is “existential suffering,” including “loss of meaning,” as from the ability to relate to others. The prospect of being “unable to interact” can be as intolerable as physical suffering, and cannot be alleviated by hospice or other palliative care.
In some countries, doctors actively administer lethal injections. No U.S. jurisdiction allows doctors to go beyond writing prescriptions for life-ending drugs to be self-administered orally by persons retaining decisional capacity.
Almost 30 percent of Medicare expenditures are for patients in the last six months of life and about 16 percent of patients die in, or soon after leaving, intensive care units. Financial reasons should not be decisive in setting end-of-life policy, but Cederquist notes that reducing “expensive and inappropriate care” -- costly and agonizing resistance to imminent death -- “is the lowest-tech thing we can do in medicine.” Hence the importance of “slow medicine geriatrics,” avoiding a “rush to those interventions that build on each other” and thereby enmesh doctors and patients in ethical conundrums.
The American Medical Association remains opposed to physician assistance in dying; the California Medical Association has moved from opposition to neutrality. Litigation has been unsuccessful in seeking judicial affirmation of a right that California’s Legislature should establish. Legislation to do this has been authored by Assemblywoman Susan Eggman, chair of the Democratic caucus.
There are reasons for wariness. An illness’s six-month trajectory can be uncertain. A right to die can become a felt obligation, particularly among bewildered persons tangled in the toils of medical technologies, or persons with meager family resources. And as a reason for ending life, mental suffering itself calls into question the existence of the requisite decisional competence.
Today’s culture of casual death (see the Planned Parenthood videos) should deepen worries about a slippery slope from physician-assisted dying to a further diminution of life’s sanctity. Life, however, is inevitably lived on multiple slippery slopes: Taxation could become confiscation, police could become instruments of oppression, public education could become indoctrination, etc. Everywhere and always, civilization depends on the drawing of intelligent distinctions.
Jennifer Glass, a Californian who died Aug. 11, drew one. She said to her state legislators, “I’m doing everything I can to extend my life. No one should have the right to prolong my death.”
The Economist reports that in the 17 years under Oregon’s pioneering 1997 law, just 1,327 people have received prescriptions for lethal medications -- about 74 a year -- and one-third of those did not use them. Possessing the option was sufficient reassurance.
There is nobility in suffering bravely borne, but also in affirming at the end the distinctive human dignity of autonomous choice. Brittany Maynard, who chose to be with loved ones when she self-administered her lethal medications, was asleep in five minutes and soon dead.
George Will’s email address is email@example.com.
00(c) 2015, Washington Post Writers Group
The havoc that Trump wreaks
WASHINGTON -- Every sulfurous belch from the molten interior of the volcanic Trump phenomenon injures the chances of a Republican presidency. After Donald Trump finishes plastering a snarling face on conservatism, any Republican nominee will face a dauntingly steep climb to reach even the paltry numbers that doomed Mitt Romney.
It is perhaps quixotic to try to distract Trump’s supporters with facts, which their leader, who is no stickler for dignity, considers beneath him. Still, consider these:
The white percentage of the electorate has been shrinking for decades and will be about 2 points smaller in 2016 than in 2012. In 2008, Barack Obama became the first president elected while losing the white vote by double digits. In 2012, Hispanics, the nation’s largest minority, were for the first time a double-digit (10 percent) portion of the electorate. White voters were nearly 90 percent of Romney’s vote. In 1988, George H.W. Bush won 59 percent of the white vote, which translated into 426 electoral votes. Twenty-four years later, Romney won 59 percent of the white vote and just 206 electoral votes. He lost the nonwhite vote by 63 points, receiving just 17 percent of it. If the Republicans’ 2016 nominee does not do better than Romney did among nonwhite voters, he will need 65 percent of the white vote, which was last achieved by Ronald Reagan when carrying 49 states in 1984. Romney did even slightly worse among Asian-Americans -- the fastest-growing minority -- than among Hispanics. Evidently minorities generally detected Republican ambivalence, even animus about them. This was before Trump began receiving rapturous receptions because he obliterates inhibitions about venting hostility.
Trump is indifferent to those conservative tenets (e.g., frugality: He welcomed Obama’s stimulus) to which he is not hostile (e.g., property rights: He adored the Supreme Court’s Kelo decision vastly expanding government’s power of eminent domain). So, Trump’s appeal must derive primarily from his views about immigration. Including legal immigration, concerning which he favors a “pause” of unspecified duration.
Some supporters simply find Trump entertainingly naughty. Others, however, have remarkable cognitive dissonance. They properly execrate Obama’s executive highhandedness that expresses progressivism’s traditional disdain for the separation of powers that often makes government action difficult. But these same Trumpkins simultaneously despise GOP congressional leaders because they do not somehow jettison the separation of powers and work conservatism’s unimpeded will from Capitol Hill.
For conservatives, this is the dispiriting irony: The administrative state’s intrusiveness (e.g., its regulatory burdens), irrationalities (e.g., the tax code’s toll on economic growth), incompetence (Amtrak, ethanol, etc.) and illegality (we see you, IRS) may benefit the principal architect of this state, the Democratic Party. This is because the other party’s talented critics of the administrative state are being drowned out by Trump’s recent discovery that Americans understandably disgusted by government can be beguiled by a summons to Caesarism.
Trump, who uses the first-person singular pronoun even more than the previous world-record holder (Obama), promises that constitutional arrangements need be no impediment to the leader’s savvy, “management” brilliance and iron will. Trump supporters consider the presidency today an entry-level job because he is available to turn government into a triumph of the leader’s will.
This is hardly the first time we have heard America singing lyrics like those of Trump’s curdled populism. Alabama Democrat George Wallace four times ran for president with salvos against Washington’s “briefcase totin’ bureaucrats who can’t even park their bicycles straight.” What is new is Trump promising, in the name of strength, to put America into a defensive crouch against “cunning” Mexicans and others.
Republicans are the party of growth or they are superfluous. The other party relishes allocating scarcities -- full employment for the administrative state.
Trump assumes a zero-sum society, where one person’s job is another’s loss. Hence his rage against other nations’ “stealing” jobs -- “our” jobs.
In 2011, when Trump was a voluble “birther” -- you remember: Obama supposedly was not born in America, hence he is an illegitimate president -- an interviewer asked if he had people “searching in Hawaii” for facts. “Absolutely,” Trump said. “They can’t believe what they’re finding.” Trump reticence is rare, but he has never shared those findings. He now says, in effect: Oh, never mind. If in November 2016, the fragments of an ever smaller and more homogenous GOP might be picked up with tweezers, Trump, having taken his act elsewhere, will look back over his shoulder at the wreckage he wrought and say: Oh, never mind.
EDITORS -- The columnist’s wife, Mari Will, works for Scott Walker.
George Will’s email address is firstname.lastname@example.org.
(c) 2015, Washington Post Writers Group
Edi Rama’s Albanian Renaissance
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Albania’s prime minister, Edi Rama, is a fiery, statuesque and decidedly well-attired politician who stands nearly 6 feet 7 inches tall. As British political operative Alastair Campbell states in his book Winners and How They Succeed, Rama is not only the tallest world leader but, as a former league basketball player, the only head of government who has represented his country internationally at sport.
In 1993, when Rama was campaigning in Tirana’s artsy fringe, Fred C. Abrahams, who was a Human Rights Watch special adviser to Albania, remembers him attired in “a T-shirt with stick figures in different sexual positions.” Now the 51-year-old prime minister prefers bright purple paisley ties, red patterned pocket squares and elegantly cut three-piece suits. Both his stature and personality have led Rama to become one of the Balkans’ most recognizable leaders—but in his clean, modest office, which overlooks Tirana’s Boulevard Dëshmorët e Kombit, it is impossible to forget his unconventional political past.
Prior to entering politics, Rama was a respected artist and exhibited in Paris, Frankfurt and New York. He still doodles on his working papers, particularly his daily schedule. These doodles are transformed into his wallpaper. Violin concertos play in adjoining hallways and construction is occasionally audible as Rama discusses his vision for the Balkans. “Both here and in Kosovo, we want to have excellent relations with everyone,” Rama tells me. “We strongly believe that what has always been a reason for dispute—for wars, conflicts, bloodshed, hatred, separation, misunderstanding—can become a huge resource for excellent relations. Our minorities should act as bridges.”
Sharing borders with four Balkan countries and shaken by two decades of weak government, Albania became a problem state that stoked conflict in the former Yugoslavia—by acting as a porous territory for organized criminal groups engaged in people trafficking, gunrunning and smuggling drugs. Since 2013, under Rama, Albania has sought to become a star pupil for EU ascension, driving forward political and economic reform. Now Albania seeks international recognition for its efforts, and it is growing impatient—particularly as EU enlargement has been stalled indefinitely by the economic catastrophe in Greece. With 7 million ethnic Albanians scattered across the Balkan peninsula and unrest flaring as recently as May in Macedonia, it’s a critical time for Albania—and the EU risks alienating its greatest supporter in the region.
Elected in 2013, Rama crushed Albania’s incumbent prime minister, Sali Berisha, in an electoral landslide that saw his coalition of left-wing parties snatch 83 of the parliament’s 140 seats, and 57.6 percent of the vote. Rama’s evolution from basketball-playing artist to politician began when he won the Tirana mayoral race in 2000 and swiftly set about reshaping the decaying city—with a pallet knife, wrecking ball and pneumatic drill. Rama ordered the facades of buildings in the city to be painted in pastel hues—primarily green, yellow and violet—and he created 23 acres of parks and open spaces in a city that he likens to “a very chaotic Ottoman bazaar.” The ensuing benefits for pedestrians, and a surge in small-business growth, helped Rama win the title of world mayor in 2004. Despite these early successes, he was not prepared for the full extent of Albania’s problems when he became prime minister. Longtime adversary Berisha had been defeated, but institutions were devastated by corruption, clientelism and links to organized crime.
“Financially, we have had to deal with a big mess,” Rama says. “The previous government had accumulated a huge amount of arrears—$700 million for unpaid public works, unpaid services to hospitals and education, and for [value-added tax] owed to companies which had not been reimbursed.... In the energy sector our distribution company had inherited a debt of $1 billion because of theft and losses in the system.” Furthermore, institutional failure had made the business community feel like the subject of a witch hunt. “People were subjected to a lot of harassment, a lot of unjustified penalties and a lot of bribery,” Rama says. Customs and the tax administration were corrupt, and “police were devastated by links to organized crime.”
In 2013, Albania stood at 116th of 176 countries in the Corruption Perceptions Index, published annually by Transparency International. By January 2015, Albania’s standing had improved to 110th. Rama has passed institutional reforms and tried to rein in corrupt businesses. As he told Albania’s Top Channel, his government’s recent investigations into Tirana’s “private universities” found some alarming practices. “We have workers of these universities, like painters or plumbers, who have not been paid in money but with diplomas,” Rama explained. “Some students have paid for their diploma with cows, sheep, rice or even firewood. We have registers saying, ‘The chief withdrew 10 diplomas.’” All 17 establishments were closed. There are other signs of progress on law and order: Police are patrolling Tirana’s roads, drivers face fines, bans on smoking in public places are strictly enforced, and tax evasion investigations are yielding serious results.
Abrahams says he believes that although initial signs are positive, the government’s success needs to be monitored. The West hastily embraced Berisha, who was hailed as an economic miracle worker in the early 1990s and returned to power as prime minister in 2005. In 1997, then-President Berisha tumbled from power after the collapse of enormous pyramid schemes that his government had supported. Two-thirds of Albanians lost a total of more than $1 billion in savings, while 2,000 people were killed in subsequent unrest. As Abrahams explains in his book Modern Albania: From Dictatorship to Democracy in Modern Europe (and tells me, via email), for now “cautious and conditional support over optimistic zeal” is what this young democracy deserves.
“I think the optimism today about Rama’s rule, and the support he’s getting from Western states, is justified—to an extent,” Abrahams says. “Rama is a very different Albanian ruler from what came before.” However, Abrahams perceives a dilemma. “At the same time, he’s also a product of that troubled political system, with its divisions, animosities and financial alliances. He has had to make deals, and those deals limit his maneuverability.”
One byproduct of the Albanian electoral system is that coalition governments are the norm. Ilir Meta, who is speaker of the Parliament of Albania and was a former prime minister under Berisha, switched his allegiance from the Democratic Party to Rama’s Socialist Party in 2013, thus allowing Rama to win the election. Meta has been hounded by allegations of corruption. While ultimately acquitted by the Supreme Court of Albania for allegedly soliciting a 700,000-euro facilitation payment to rule favorably in a deal to build a power plant, the incident triggered widespread demonstrations in 2011—which were headed by Rama himself, then in opposition. Albanian tabloid newspapers often speculate about the nature of this alliance, but Abrahams suggests that Rama’s ability to work alongside Meta displays an ability to compromise in a country where lack of dialogue has often caused progress to stall.
Alastair Campbell, who is best known as Tony Blair’s former political strategist, helped create Rama’s 2013 electoral landslide. He tells me, in a telephone interview, how they first met on the margins of a Tirana conference. Rama had lost the mayoral race to Luzlim Basha and was disillusioned by the state of Albanian politics. They subsequently agreed to work together, and Campbell describes the “sheer brutality” of Albanian politics. “Edi is both trying to win against this kind of attitude and also trying to change it. He has to be both very tough and also very empathetic,” he tells me.
Among the challenges Rama faces is how to resolve ethnic tensions with his Balkan neighbors. Just days before he was due to meet his Serbian counterpart last October for the first such meeting in 68 years, a European Championship qualifying match between the two countries was abandoned after an unmanned drone hovered over the field carrying below it a Greater Albania flag—a reference to the nationalistic idea of an extended territory covering all the areas where ethnic Albanians live, including Kosovo. A Serbian player ripped down the flag, and brawls between players resulted in the cancellation of the game. Rama’s brother, Olsi, was accused, without basis, of operating the drone, and the prime minister stepped in to resolve the tension through talks with Serbian Prime Minister Aleksander Vucic and German Chancellor Angela Merkel.
Rama says Europe needs to do more to welcome the Balkan nations. “Today, we have a peace in this region that we did not have in our history,” he says. “And this is not the result of any evangelization of us. We are not angels and will never be—but this peace is the result of the aspiration of all of the people in this area to be part of Europe. If Europe will continue to show fatigue from enlargement, it risks seeing this region fatigued of patience. If patience is over, the Balkans will always become identified with bloodshed.” Rama pauses. His forehead furrows, and his eyes appear wide and thoughtful. “Letting the Balkans, and its multi-religiosity, disintegrate would be a tragedy for every one of us.”
(c) , Newsweek, Inc. All rights reserved.
Trump defines down the GOP
WASHINGTON -- It has come to this: The GOP, formerly the party of Lincoln and ostensibly the party of liberty and limited government, is being defined by clamors for a mass roundup and deportation of millions of human beings. To will an end is to will the means for the end, so the Republican clamors are also for the requisite expansion of government’s size and coercive powers.
Most of Donald Trump’s normally loquacious rivals are swaggeringly eager to confront Vladimir Putin, but are too invertebrate -- Lindsey Graham is an honorable exception -- to voice robust disgust with Trump and the spirit of, the police measures necessary for, and the cruelties that would accompany, his policy. The policy is: “They’ve got to go.”
“They,” the approximately 11.3 million illegal immigrants (down from 12.2 million in 2007), have these attributes: Eighty-eight percent have been here at least five years. Of the 62 percent who have been here at least 10 years, about 45 percent own their own homes. About half have children who were born here and hence are citizens. Dara Lind of Vox reports that at least 4.5 million children who are citizens have at least one parent who is an illegal immigrant.
Trump evidently plans to deport almost 10 percent of California’s workers, and 13 percent of that state’s K-12 students. He is, however, at his most Republican when he honors family values: He proposes to deport intact families, including children who are citizens. “We have to keep the families together,” he says, “but they have to go.” Trump would deport everyone, then “have an expedited way of getting them [”the good ones”; “when somebody is terrific”] back.” Big Brother government will identify the “good” and “terrific” from among the wretched refuse of other teeming shores.
Trump proposes seizing money that illegal immigrants from Mexico try to send home. This might involve sacrificing mail privacy, but desperate times require desperate measures. He would vastly enlarge the federal government’s enforcement apparatus, but he who praises single-payer health care systems and favors vast eminent domain powers has never made a fetish of small government.
Today’s big government finds running Amtrak too large a challenge, and Trump’s roundup would be about 94 times larger than the wartime internment of 117,000 persons of Japanese descent. But Trump wants America to think big. The big costs, in decades and dollars (hundreds of billions), of Trump’s project could be reduced if, say, the targets were required to sew yellow patches on their clothing to advertise their coming expulsion. There is precedent.
Birthright citizenship, established by the 14th Amendment and opposed by Trump and his emulators, accords with America’s natural-rights doctrine. Arguably, this policy is unwise. But is this an argument Republicans should foment in the toxic atmosphere Trump has created, an argument that would injure the next Republican nominee even more than Mitt Romney injured himself? Romney, who advocated making illegal immigrants’ lives so unpleasant they would “self-deport,” might be president if he had received 10 points more than his 27 percent of the Hispanic vote.
About 900,000 Hispanic citizens reach voting age each year. In 2012, less than half of eligible Hispanics voted, but Republicans have figured out how to increase Hispanic turnout.
A substantial majority of Americans -- majorities in all states -- and, in some polls, a narrow majority of Republicans favor a path for illegal immigrants not just to legal status but to citizenship. Less than 20 percent of Americans favor comprehensive deportation.
This may, however, be changing now that so many supposed Republicans embrace a candidate who, six years into Ronald Reagan’s presidency, disparaged Ronald Reagan as someone who tried to “con” the public. Looking on the bright side, perhaps Trump supporters are amiably broadminded in their embrace of a candidate who thinks we cannot presently be proud to be American citizens (he says his presidency will enable us to again be proud).
If, after November 2016, there are autopsies of Republican presidential hopes, political coroners will stress the immigration-related rhetoric of August 2015. And of October 1884.
Then, the Republican presidential nominee, former Sen. James G. Blaine, returning home to Maine in the campaign’s closing days, attended a New York rally on his behalf, where a prominent Protestant clergyman said Democrats were a party of “rum, Romanism and rebellion.” Catholics, many of them immigrants, noticed. Blaine lost New York, and with it the presidency, by 1,200 votes out of more than one million cast.
EDITORS -- The columnist’s wife, Mari Will, works for Scott Walker.
George Will’s email address is email@example.com.
(c) 2015, Washington Post Writers Group