The Business Case for Managed Death

Supporters and critics of physician-assisted suicide agree on at least one thing: terminally ill patients who take an early exit save the health care system money.

Nationally, legal euthanasia for terminally ill patients could cut American health-care costs by $627 million per year (less than one-tenth of 1 percent of total expenditures), according to a New England Journal of Medicine article by doctors Ezekiel Emanuel and Margaret Battin, who each come down on opposite sides of the ethical argument over assisted suicide.

But could the business case for managed death push health insurance companies to pressure their customers into taking their own lives before they’re ready?

That’s one of the questions in a debate raging in Washington State right now, as voters there are set to decide on a ballot measure that would allow doctors to prescribe their terminally ill patients lethal doses of drugs on request.

Critics of the measure point to the story of Barbara Wagner, a cancer patient in neighboring Oregon, whose insurance company denied her request for coverage of potentially life-saving drugs, and instead offered her money for lethal drugs. Oregon is currently the only state where doctor-assisted suicide is legal.

Does the legalization of physician-assisted suicide incentivize early death?


SuAnne

Yeh! Bring it on. My friends and I (in our 40s and 50s) who don't have kids have already been talking about this issue. I began thinking about it 20 years ago realizing then that social security would likely not exist. The thought of getting old in this country is frightening.

A healthy perspective on living and death is something our culture obviously lacks. We're obsessed with NOT getting old, (fear of dying?) and schizophrenic to boot with our pro-lifers, death penalities, war criminals, and pet health care plans. I think we're full of ourselves, frankly.

I'd welcome the option to legally bid farewell on my terms and would support others whom I loved to do so too.

erik de koster, brussels

this is a tough subject.
The patient's wishes should certainly be the centre of this debate, and a lot of resistance to assisted suicide stems from institutions that have a vested interest in denying rights to people (churches are a good example, followers thinking for themselves, what a dangerous idea (sic)). The suggestion from this lady's insurance company is despicable (and I think outright criminal), but then again, a lot of decisions of insurance companies have nothing to do with benefits to the subscribers of their insurance policies. Patients should be very clear about their death wish: it is not always clear what an ailing patient means when he sighs in desperation that he would like to be dead, maybe being very happy a week later that he didn't do anything to hurt his life a week earlier. In countries which have euthanasia laws such as belgium or holland, rules are very specific, and the procedure is quite constraining. Nevertheless, the highest dissatisfaction with current rules in Belgium comes not from people who oppose the rules, but from people (including patients) who want to extend them, especially to under-18 children, who have currently no legal right to euthanasia, even though many of these children, usually suffering of cancer or rare genetic conditions, have already lived through more harrowing experiences than most adults, and seem to be a lot more adult about their life's choices than many adults.

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Mike B

I am surprised that few people discuss the moral implications of opportunity costs in prolonging the life of terminally ill patients. Frankly I see the case for using group resources, insurance or public, to slightly prolong the life of a dying patient as morally indefinable. We do not live in the Garden of Eden, there are very finite resources to be spent on medical care and every dollar that is spent to prolong the life of a terminally ill person cannot be spent on someone with a better return on the medical investment.

People will say that money can be found in the profits of the insurance companies or from tax revenue, but where the money comes from is immaterial, it would still be better spent on saving the life of a person who stands a chance of living for years as opposed to months. If people want to eek out a few extra months it should be incumbent upon them to save up the money early in life or buy specialty insurance that does not impact the cost of basic insurance.

Medical resources are mis-spent chasing last ditch treatments to reverse normally terminal conditions like late-stage cancer. People need to have the cancer caught early when treatments are much more effective. The prospect of a "miracle" might actually disinventivize people from being proactive about their health. Shutting the door on publicly paid end of life heroics would further nudge people in the right direction.

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Judy G. from Fairfax, VA

The real problem here is the willingness of some "entity" which is in it for the money to intrude into end of life decisions. It's all absolutely horrendous-whether they're trying to make you keep living, or as suggested in this article, trying to hasten your death, and all based on some outsiders sticking their noses where they don't belong.

Given our present rapacious business model ("greed is good," and the "bottom line is all we care about") the steps from paying for treatment, to influencing treatment, to withholding treatment, to encouraging treatment that will hasten a death are short and quick.

I think that the private sector has taken this perverse notion into its collective heads from the case of Terri Schiavo, during which the government decided IT wanted to make people pretend to live on after they're long dead. I say perverse because now the insurance companies, having been given the "model," have yet again twisted it out of all reality so that it's now acceptable to encourage dispensing drugs that will kill you quickly, so they can save a buck.

People should be free to make their own choices about end of life care, without interference by either the government or the insurance companies. The "government" got this started and in so doing has given the insurance companies, the hospitals, and the doctors, the idea that this behavior is somehow "OK."

It is NOT OK. The business community has demonstrated that absent regulation, it will do any indecent thing, previously short of murder, that it thinks it can get away with, if it will save them one "mill" on the buck, and NOW, they're willing to take the last step to murder.

So much for the phony bunk of "conservatives." We'll only stop it with regulation, something the GOP abhors to its very soul. Then again, however, the GOP is anything BUT conservative.

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htb

Dennis (@48): Why should the physician be involved at all? Then the cost of suicide for a terminally ill patient could be just 10 bucks, with no added cost for a medical professional (and the usual law requires the significant involvement of several expensive professionals, which is one of the reasons that most terminally ill patients don't use that process to kill themselves).

Why should the typical terminally ill person need a physician to do what thousands of mentally ill people manage (unfortunately) to do on their own every year?

fairlee76

re: muerta. pharma makes a lot more money in current "maintain life irrespective of quality thereof" system than it would make under a managed death system. the money is in the maintenance, not the cure.

Roger

If my health insurance is with BlueCross/BlueShield,
but my life insurance is with someone else (obviously), will my family be able to collect on my insurance? Traditionally, life insurance doesn't pay for suicide. Would the life insurance company pay? Would I have to prolong my life, unwillingly (and potentially in agony) only to run up hospital bills that could only be paid by my life insurance policy? Or could I elect an "early" exit, allow my wife to collect my life insurance payout, pay off the house and live in relative security?

At the least, if the interests of the health insurance and life insurance companies aren't aligned, this is going to be a problem.

M

Maybe it's been missed, but the insurance company doens't have to 'decide for you' on whether you'll get treatment or hemlock. All they have to do is charge you a thousands of dollars out-of-pocket on the one hand, or offer you a small lump some on the other, and by incentivizing your decisions, it can dramatically sway your choice.

KDG

#37
There was a time I would have agreed wholeheartedly, but now I am not so sure. I work at a rehabilitation hospital and everyday we see new technologies improving the quality of life of people here who many would say should just get it over with and die. With new communication tech, an ALS patient here can still speak with family members, surf the net and work - yep, work. There are many other examples. In fact, some of the new tech we see gives back mobility thought to be permanently gone - giving new options to people that even a few years ago would have been written off (many even by themselves) as "useless." Who is to say...by helping someone stay alive a little longer, they might have a shot at a new treatment. Is it worth the massive cost? Wish I knew, but there are many who walk out of this place thinking probably, "yeah."

David Chowes, New York City

ANOTHER LOOK AT THE IMPLICATIONS OF MANAGED DEATH:

It may sound strange to say that life is a mystery sans meaning. We don't know why we're here -- and I suspect that there is really no answer other than to pass our genes forward.

Much of life is unfulfilling and quite a good deal is painful.

If there is a nirvana, it occurs before life and after death. Ergo, nirvana equals nothingness.

Given what I just said, I can tell you that I am against 'managed death.' Why?

We all tell ourselves naratives -- icluding many Americans and most other people, which indicate how wonderful life is. A canard. Organized religions and other 'faiths' are some of the myths which make life more bearable.

So, if "managed death" becomes more normative --
we all would have to be in far greater touch with the true nature of life -- which is frequently quite unpleasant; always terminated by death...

If you say that this is a case of [Freudian] denial -- of course you're right...

I believe the anti-abortion battle is waged by many to GIVE LIFE A MEANING IT DOES NOT HAVE.

Yes, we need a degree of denial to give our lives the menaing it lacks in that brief period between the 'two nirvanas.'

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Ben

I'm not completely opposed to letting terminally ill patients make such a choice, but I absolutely detest the idea of insurance companies getting control over the decision on spending $4,000 per month to *maybe* keep me alive vs. $50 to get rid of me for good.

Grant

I wrote a paper on the legal issues surrounding physician assisted suicide and euthanasia (not the same thing). I think the slippery-slope argument and the general moral repugnance of the concept hold a lot of weight. I'm still unsure where I stand on the issue. It's just too hard to wrap my brain around.

Ben

Perhaps if it is legal to prescribe lethal drugs, it should be illegal for insurance to cover them since it would be a conflict of interest.
Similar to how "wellness" programs at many hospitals are kind of a conflict of interest for them.

Chris

The business side of the pharmaceuticals industry will find a way to incentivize anything that is suddenly made legal.

I can't wait to see the drug company commercials when this happens: "Ask your doctor if new Muerta is right for you..."

And will they still have to read us the list of possible side effects?

Ed Haines

I have not seen recent data from Oregon, but my understanding is that very few persons have utilized the opportunity for physician assisted suicide. However, many terminally ill persons have expressed the sense of relief from knowing that this option is available. This does not sound like a very "slippery slope".

I am intrigued by Ben's suggestion. I can see the advantage to be found from removing insurance companies from the decision matrix facing people and families in terminal illnesses.

P.Diddy

A side note: "incentivize" is not a word.

meter

@38 - you're already consuming good & services that you probably couldn't afford if put entirely in the hands of the free market.

Examples: electricity, water, public transportation, etc.

christa

@htb #19

I'm sure the emotionally dependent dead care a great deal about what you think of them, wherever they end up.

jimi

@35- Why should I or anyone else be entitled to any service that I or he cannot independently pay for?

matt

We've created another unsustainable 'bubble' with advanced technology to sustain lives. Few people want to have the conversation even in their own family, let alone in political chambers. Just because we 'can' keep someone alive for years and years, doesn't mean that we should. I can certainly understand how painful that is on a personal/individual level, but on the macro level, something has to give at some point.