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Posted on September 25, 2016 at 4:11 PM

by Steven H. Miles, MD

A friend of mine is dying of metastatic cancer. She does not have long to live; she will possibly die before the end of this year. Throughout her life, she actively participated in civic life. She donated her time and money to charities and political campaigns. She did not shirk a call to jury duty as many do. Disability from her illness has constrained her public life. She watches television when she is not too tired. She follows a prominent local race and a race for national office. This week, I will take her to city hall to cast her ballot for the 2016 election.

One might ask, ‘Why?’ A harsher perspective might even maintain that she should not vote because she will likely die soon after the election. She might even die before the election in which case, one might argue that her ballot is analogous to the extremely uncommon, but not apochryphal, stories of fraudulent ballots cast in the name of decedents. Such a story is now unfolding in Colorado, a ‘battleground’ state in the upcoming presidential election.[i] Depending on whether my friend dies soon after or before the election, one might argue that she has either a marginal stake or an illegitimate role in this election. Assisted voting, however legal or desired by her, is hardly to be commended and perhaps might be morally condemned. I disagree.

Dying persons have a variety of future-looking interests that survive them. In writing a will, they gift possessions to particular family members and charities so that those persons and organizations might be cared for and sustained by the decedent. In signing organ donor cards and anatomical gift bequests, they direct that their remains be used to benefit others in some future time. A stranger may receive those organs. A community far distant in time and place and medical interests may benefit from research on gifted tissues. By such means, dying persons’ interests live on after death overtakes the body.

Although, it is widely argued that funerals are for the survivors who properly decide how to memorialize a life, dying people have legitimately respected preferences for funerary practices. For ecological reasons, they may direct that they not be embalmed, thereby keeping three gallons of formaldehyde from leaching into acquifers. They may request a cremation or green burial without the toxic, non-biodegradeable, or ecologically harmful material fittings of conventional services.[ii] Many Jews desire to be buried in a plain wooden coffin without metal fasteners or shellacs where local laws preclude interment in a simple shroud. People have preferences with regard to their open casket viewal or cremation that are worthy of respect regardless of the survivors’s selection of the words and music of the funeral service. All of foregoing, simply show that we respect the future-looking preferences and interests of people who are about to die.

I believe that such forward looking preferences commend assisting persons hospice programs for early absentee voting. Persons in hospice programs do not live very long. The average length of enrollment is about two months, shorter than when this election’s candidates will take office. Persons in hospice are not legally constrained from voting and there is no move to impose such a constraint. Early voting has started in several states and more will make in possible in the weeks remaining until the election. States differ however on how they handle the absentee ballots of persons who die before election day. Some states say that such ballots should be voided; others do not have provisions to void ballots. The issue is especially poignant for soldiers who vote from the battlefield and die in combat before election day. Persons who are aware that a person who has died of expectedly or unexpected circumstances should notify the registrar in states that void such ballots. Such laws have no effect on the voting of persons who are alive on election day and die before candidates take office.
In these circumstances, every vote (whether cast by a person who is imminently dying or one whose death lies at an unenvisioned distance) is a bequest of a future world for those who survive the decedent. The votes each of us cast ten years ago, helped configure the possibilities of access to health care, student loans, and efforts to prevent global warming for our present day and for our grandchildrens’ days after we are gone. Voting is a forward-looking preference. Respecting this preference falls entirely within medical ethics enshrined principle of respect for personal values and autonomy.

It is entirely proper to give the gift of assisting persons in hospices and persons who are confined by illness to cast their vote.

[i] CBS Denver. CBS4 Investigation Finds Dead Voters Casting Ballots In Colorado. Sept 22, 2016

[ii] Langtree I. Cemeteries: Environmental Pollution & Groundwater Contamination. Disabled World. Oct 8, 2015.

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