Even in defeat, Proposition 161 sounds a warning.

Occasionally law that isn't made may be as significant as law that is. One such instance was the rejection on 3 November of Proposition 161 by a 54-46 majority of California voters. Had this initiative passed, the state would have been the first in the world since the Nazi era formally to permit physicians to perform active euthanasia. Even though defeated, the strong showing for this ballot measure--and the even stronger support it enjoyed outside the voting booth--sounds a loud alarm for health care professionals not just in California but across the country. Proposition 161's defeat should not obscure the remarkable fact that millions of people are so fearful of how they think they'll be treated by the health care system when they're very ill that they'd rather be dead. Surveys taken in March and April this year showed that 75 percent of California voters favored the basic concept of physician aid-in-dying, 54 percent strongly so. The percentage who opposed active euthanasia on moral or religious grounds stayed relatively constant from the early surveys until election day. But the ranks of those voting no swelled as the opposition coalition focused its advertising during the final weeks on what worked a year earlier to bring down a similar measure in Washington State by an identical margin: voters' fears that mistakes would be made. Among those who voted against, 43 percent told exit-pollsters that inadequate safeguards was the primary reason for their opposition. Not surprisingly, the measure fared best among more liberal, highly educated, and younger voters. Male voters split 50-50, while females opposed 56-44; whites were only slightly opposed (52-48%), but the margin of defeat among black and Hispanic voters was 20 percent. What this suggests is that less powerful people (such as older, minority women) felt themselves more at risk from the measure, fearing that a policy of active euthanasia might be used against them because the law would provide insufficient protections for them. Second Warning The public has now twice given notice that something radical has to be done about the care of dying patients. Although specific aspects of the legislation proposed have caused some voters to back away from approving laws that they support in principle, a euthanasia initiative might well pass if physicians and others fail to remedy the underlying problems that propel this issue onto the public agenda. If resources were the only problem, the health care system should be able to respond--after all, it consumes nearly one dollar in every six of our gross domestic product. Yet despite (or perhaps, because of) the system's extraordinary array of life-saving technology, average people are so dissatisfied, so dismayed at how death occurs in this country, and so distrustful of physicians' ability or willingness to give them a "good death" that they will consider overturning thousands of years of medical ethics and societal prohibitions to legalize direct killing by physicians. Some of those who favored Proposition 161 may have done so under the mistaken but unfortunately widespread impression that it was needed if patients are to avoid having their dying extended indefinitely by artificial means, such as respirators and tube feeding. In California and virtually every other state, patients need have no such fears, as the law protects their refusal of life-extending techniques beyond the point they judge to be of value, and allows authorized surrogates to refuse on their behalf if they become incapable of making their own decisions. Yet if some voters favored Proposition 161 to avoid an artificially extended dying, that merely shows the system has failed to educate patients about their rights, to encourage them to communicate their wishes about care at the end of life, and to reassure all concerned that respecting patients' wishes entails no risk of criminal or civil liability. …