Covert rationing and end-of-life healthcare 

In the last two sections we have surveyed how covert rationing corrupts the actions of managed care organizations and of the regulators, all of whom are supposed to be (and insist to us they are) protecting the health and welfare of Americans.  In this section we'll look at an aspect of covert rationing that may be even more disturbing and ultimately more consequential than either of these.

The issues surrounding end-of-life medical care are of vital importance both to individuals and to society. Perhaps more than any of the other issues we have discussed, the way we handle end-of-life care will determine what kind of a people we will become in the 21st century.

There are actually three areas of hot contention related to "end-of-life" medical care - these issues are advance directives, physician-assisted suicide, and medical futility. In my book The Grand Unification Theory of Health Care, I discuss all three end-of-life controversies. On this website I limit the discussion to the most contentious one of the three - physician-assisted suicide.

All three areas of end-of-life controversies involve legitimate ethical dilemmas, about which respected ethicists have argued and continue to argue on either side.  In each case the ethical point of contention is the same - that of individual autonomy versus the needs of society as a whole.  In essence, all three ask this question - how much authority will a patient be permitted in gaining some control over the events that surround his or her own death?

The autonomy of the individual - a person's right of self-determination - is a cornerstone of the American belief system.  Yet, individual autonomy is not perfect even in concept; it has inherent limitations. In the individual's pursuit of life, liberty and happiness, no person has the right to limit or jeopardize the rights or welfare of other individuals (i.e., of society).  This limitation creates an unavoidable tension between the rights of an individual and the needs of society.  Indeed, the general problem of how to protect individual autonomy without sacrificing the legitimate needs of the collective accounts for many of the domestic conflicts that have taken place during our nation's history.  

Not surprisingly, the issue of autonomy is central to the end-of-life disputes. Acknowledging that the dying patient has the right to make critical healthcare decisions often provides a final measure of control and dignity to his or her life.  To those in the "end-of-life" movement, the battle is for affirmation of the individual autonomy of the dying patient, and against the technocratic, unfeeling healthcare machine that is too intent on following its own rules and procedures.

There might be no conflict at all if the individual's end-of-life desires did not place certain demands on society.  But when dying patients ask that their own death be hastened, a certain tension is created. The tension arises from the fact that our society, as a requisite check on the sovereign authority (that is, the authority which has the ultimate power to assert its will over all other authorities, whenever necessary, by the use of violence). In American society this sovereign authority (the government) is obligated to jealously honor and protect the physical life of individuals. So when individuals demand that healthcare providers stop protecting their physical existence or even act to end it, and further, that the state embrace those demands, a potential conflict is created. And it is necessary to consider whether such demands might begin to erode an essential aspect of our social contract.

This question is difficult enough on its own.  It becomes virtually unsolvable when put into play in a milieu of covert healthcare rationing.

Central to the end-of-life disputes, though not often openly discussed, is the issue of cost.  In virtually every plea for the expansion of end-of-life autonomy is an aside (often in parentheses) as to how much money is being spent today caring for patients in the last few months of life.  Up to 35% of Medicare expenditures in any given year, we often hear, will go to the 6% of enrollees that die within that year.  The clear implication is that, by honoring individual autonomy, as a bonus we also stand to save countless millions of dollars. There is an undeniable and increasingly compelling financial incentive for society to yield on its jealous protection of individual life. It ought not to be surprising, in this light, that those who cut the checks, the health insurers and the government, have generally expressed great sympathy and support for at least some aspects of the end-of-life movement.  

And as we will see, covert rationing turns the issue of end-of-life autonomy on its head. For, under a system of covert rationing, placing the autonomy of the dying person above all other considerations will ultimately devalue the worth of the individual.

Physician-assisted suicide

Aside from abortion, there is no controversy in medicine more contentious or polarizing today than that of physician-assisted suicide.  Proponents of assisted suicide usually invoke a prototypical scenario to illustrate their position: Consider the patient riddled with widely metastatic cancer, facing an all-too-slow but inevitable death, and suffering from severe, uncontrollable pain.  Does not such a patient have a right to ask his or her physician to give them the means to end their suffering once and for all?  And does the physician not have the right to respond to that human need without committing a crime?

It is an extremely compelling question.  Accordingly, this is the kind of scenario that has been posed to the public in most polls whose results appear to show that the majority of Americans are in favor of physician-assisted suicide. Few would argue that this terminal, pain-wracked patient does not have a right to expect his physician to do whatever it took to relieve his suffering.  Few would want that physician to deny the desperate pleas of the patient.  Most would believe it unethical for a doctor to deny those pleas.

Nonetheless, with good, compassionate medical care, this very difficult clinical problem ought to be rare; it should be manageable in most cases without having to resort to assisted suicide.  In the large majority of patients with terminal pain, symptoms can be controlled with pain medication, even though the medication may need to be given in very high doses or by novel routes of administration, and even though doing so may run the risk of hastening the patient's death.  This aggressive use of pain control measures in terminal patients is not only usually quite effective, it is also entirely consistent with professional standards of behavior. It honors the autonomy of the individual patient, and does so without impinging on the rights of society. Certainly there will be occasional instances where even extremely aggressive pain management fails to adequately control pain, and leaves the patient asking for death.  But with adequate, creative and aggressive pain control efforts, such instances are very uncommon.

Unfortunately, some doctors just don't understand pain management techniques, or are too afraid to use them, and as a result too many patients are suffering needlessly as their lives draw to a close.  However, it somehow does not seem appropriate to just go ahead and kill the patient as the first option in redressing this medical shortcoming. A better approach, one might think, would be to insist on improved physician education and clear professional standards for pain control.

While the argument for assisted suicide invariably centers on relieving the suffering of terminally ill patients with intractable pain, in actual practice these are often not the individuals who seek this remedy.  By and large these were not the patients who sought out Dr. Kavorkian, the famous assistant of the suicidal. Most who requested his assistance wanted to end their lives for other reasons, commonly because they suffered from disease-related depression, a debilitating sense of losing control over their own destiny, or fear of becoming a burden to their families.  Some did not even have terminal illnesses. This is a pattern that holds up in Holland, where assisted suicide and euthanasia are acceptable as a matter of public policy.  Intractable pain is the motivator in only a decided minority of Dutch patients who ask for assisted suicide.

Whatever the real-life usage of this "therapeutic option," however, there clearly is a vigorous and often passionate movement in the U.S. in support of physician-assisted suicide. Some of the impetus for this movement undoubtedly derives from a genuine belief that individual autonomy needs to be rescued from the clutches of the unrelenting, unfeeling, smothering bio-techno-medical machine. In others it probably derives from some underlying psychological disorder. (It seems possible to me that Dr. Kavorkian, for instance, might have broader ties to pathology than merely that it was his profession.)  In still others it may be a vehicle for a political voice.  And without a doubt there are more than a few supporters of assisted suicide who have gone through the trauma of witnessing a loved one experience nightmarish end-of-life medical care at the hands of amateurish physicians.

The debate over assisted suicide is fundamentally a debate over medical ethics. The clear majority of medical ethicists seem to have come down strongly in favor of this practice, since the right to assisted suicide is so clearly a win for the vitally important principle of individual autonomy.

But while I have stressed the importance of individual autonomy throughout this book (indeed, one of my major themes is that individual autonomy needs to be saved from the ravages of covert rationing), close examination of the ethical question suggests that in the case of assisted suicide, at least under our present paradigm of covert rationing, the unbridled endorsement of end-of-life autonomy threatens to lead us precisely to where none of us say we want to go - ironically, it will lead to the coercion and devaluing of the individual.

The ethics of physician-assisted suicide

The arguments advanced by professional ethicists regarding end-of-life medicine can be difficult to follow. This is too bad, since couching ethical opinions in jargon and arcane twists of logic places the rest of us in the position of having to accept the ethical bottom line without really understanding how that bottom line was reached.  It reduces ethics to "received knowledge," and elevates professional ethicists to a priesthood.  Advancing unintelligible ethics is, well, unethical.

In any case, once you cut through the argot, here is how most of today's medical ethicists seem to regard the issue of end-of-life autonomy in general, and physician-assisted suicide (and its close cousin, euthanasia), in particular:

Point 1) We as a society have already decided that the individual patient's autonomy is the deciding factor in making decisions on ending life.  We made this decision when we formally asserted the individual's right to refuse medical treatment (and to have treatment withdrawn), even life-sustaining treatments, and even if the disease for which treatment is being refused is curable. This was the critical ethical choice for us, and we have made it.  Thus, we have already decided that passive euthanasia - letting nature take its course - is ethical if the patient desires it.

Point 2) There is no ethical difference between "passive" and "active" euthanasia.  That is, there is no difference between "letting nature take its course" and helping nature along a bit.  In one case, the doctor acts to remove or withhold life-sustaining therapy, thus hastening death. In the other case, the doctor acts to administer the means of hastening death.  In either case, the doctor has taken an action that hastens death - the two acts are ethically equivalent.

Point 3) Once active euthanasia has been determined to be ethical, there are no remaining ethical grounds for objecting to the lesser question of physician-assisted suicide. If it is ethical for a doctor himself to act to hasten death, there can certainly be no objection to his handing the patient the switch that triggers the suicide machine.  

Conclusion) Since we have already asserted the right of the patient to refuse life-sustaining therapies, ethical consistency also requires us to allow both physician-assisted suicide and active euthanasia.

As nearly as I can tell, most ethicists believe the Supreme Court was wrong in 1997 when it denied a constitutional right to assisted suicide. Furthermore, many ethicists were scandalized that the Court made a clear ethical distinction between "letting nature take its course" and hastening death, especially since it did so in the face of nearly unanimous agreement of the ethics community to the contrary.

The bottom line is that, from the standpoint of most experts, the same ethical principle of individual autonomy that makes it acceptable for patients to refuse life-sustaining therapy also renders physician-assisted suicide (and active euthanasia) entirely ethical.  Thus, there is no generally accepted ethical barrier to either.

And here is the problem I have with the analysis medical ethicists have generally advanced on this issue. By admitting that patients have the right to refuse medical therapy (and how could we, by any stretch, do otherwise?), we have embraced the principle of individual autonomy apparently to the exclusion of all else, and have instantly triggered an elaborate chain of logic that finally requires us - in order to be ethically consistent - to sanction not only assisted suicide, but also active euthanasia and who knows what else.  There's got to be another side to the story.

The other side to the story is that the right to individual autonomy simply cannot be absolute, any more than any other ethical principle can be absolute.  Ethical principles, in fact, often live in a natural state of conflict with one another. When two valid ethical principles are in conflict, we call that an ethical dilemma; and the proper job of an ethicist is to help us think about ways of resolving these dilemmas. This is best done not by completely abrogating one of the conflicting principles (since both principles are, by definition, important), but attempting to achieve a reasonable balance between the two, aimed at optimizing the overall results. When a medical ethicist says, "Sorry, my boy, but individual autonomy is all there is to it, and all other considerations can go pound salt. We have no choice but to follow the principle of individual autonomy to wherever it may lead us," as I see it he is derelict in his duties. Such ethicists can be dangerous.

It is undeniable that in any culture, the rights of the individual will inherently be in conflict with the rights of society at large.  Which rights ought to predominate will vary from society to society, and even from time to time.  In socialist countries the rights of the collective virtually always have primacy over those of the individual.  In contrast, in the United States, by our very founding documents, the rights of the individual ought to predominate - but to be predominant is not the same as being unchecked.  

Clearly, the question of physician-assisted suicide presents us with an ethical dilemma.  For insisting on absolute individual autonomy in this case will significantly impact our entire society.  Before we fully endorse assisted suicide - opinions of medical ethicists to the contrary notwithstanding - we must perform a sober assessment of how the rights of society might be impacted by it.  And the cost to society simply cannot be adequately estimated without considering that in America, our society is one in which the covert rationing of healthcare is a fundamental fact of life.

The impact of physician-assisted suicide on society

The cost-saving aspects of physician-assisted suicide, and where it will lead

The cost-saving aspects of physician-assisted suicide are rarely discussed openly. Yet, these aspects reside just beneath the surface of many passionate arguments for legalization of assisted suicide.  It's purely an issue of autonomy, these arguments go, but hey, as it turns out it's also a win-win for both sides.  The individual gets his autonomy, and society saves a little money to boot.

When it comes to assisted suicide the payers have wisely stayed pretty much on the sidelines. It would be unseemly, at least for the moment, for either Wonkonians or Gekkonians to become big boosters of assisted suicide, and besides, so far medical ethicists are doing a good job of carrying the ball.  Patience is the order of the day.

It would be too much, however, to expect that such reticence would persist even after assisted suicide became widely available.  After all, once our society decides that assisted suicide is a legitimate means of expressing one's autonomy, wouldn't it be the duty of government and insurers to establish smooth processes by which such autonomy could be expressed?

Already the enthusiasm for potential savings occasionally bubbles to the surface. For instance K.K. Fung, a professor of economics, argues that tremendous cost savings could be realized by using financial incentives to induce patients with terminal illnesses to end their lives. (Fung KK. The American Journal of Economics and Sociology 1993;52:275.) His plan, blandly called "physician-assisted death with benefit conversion," would pay such patients, or more probably, their estates, a very nice sum (based on a percentage of what otherwise would be spent on their healthcare), to instead opt for a voluntary, painless, and dignified death at the hands of their doctors and at a time of their choosing.  Thus, not only should voluntary physician-assisted suicide be made legal; but we should also take steps to encourage this choice as a means of reducing the cost of healthcare.

While such a proposal might look totally outlandish to many of us, it simply places a logical Gekkonian spin on what is more typically a Wonkonian issue. The only reason such a scheme seems over the top to us, Gekkonians might say, is that our thinking has not yet "evolved" sufficiently.  We just need a little time to get used to the idea.

This example points out the corrupting influence that covert rationing will have on what otherwise might be an issue of ethics. Physician-assisted suicide as an occasional and extraordinary solution to a rare, intractable clinical dilemma is one thing; institutionalized and encouraged as one of several healthcare options, however, it will become quite another.

Without going into flights of imagination, one can easily visualize the promotion of assisted suicide as an attractive choice, as a new individual freedom, hard-won from the paternalistic healthcare system.  Magazine adds and pamphlets (included with your hospital admission packet) will tell how you have the power to save yourself from the clinching grasp of the medical automatons, to be rescued from their needles, biopsies and scans, to take control of your destiny, and remove yourself to a place where, free from pain and enveloped by peace, you can be eased into the next life.  You no longer have to suffer. You no longer have to worry about being a burden to your family. It's in your power to do one last thing for yourself and for the ones you love.  It's your choice, you are told lovingly - and expectantly.

And you can be sure that, even if you choose not to listen to this stuff, your children and grandchildren will. And even if they don't say it, sooner or later they'll be thinking, "Well, it's sort of getting to be about that time, isn't it?"

And before you know it, the choice for assisted suicide will become the duty for assisted suicide.

Devaluing end-of-life care

In our healthcare system today, we pay a lot of attention to those who are dying.  The hospice movement is strong, and medical research in recent decades has helped immensely with caring for the physical and emotional needs of the dying.  Resolution of many personal, emotional, and family issues are facilitated in the last days of life, thanks to the recognition that these things are of vital importance not only to the patient, but also to those the patient will leave behind.  Yet, such efforts are expensive and emotionally taxing, even for those who have developed expertise in end-of-life care.  

If an easier (and cheaper) way were available, careful and compassionate end-of-life care would be de-emphasized.  "We don't need it any more," HMOs would say.  "People are choosing suicide, in celebration of their autonomy." And by making good end-of-life care harder to come by, they indeed would be rendering assisted suicide a more attractive choice.  

Making society callous to suffering

While nobody likes to talk about it, suffering people are, to at least some extent, insufferable. In their emotional and physical pain, they can be demanding, self-absorbed, and sometimes abusive.  They often need constant, difficult, and highly unpleasant care. No matter how compassionate we caretakers may be - healthcare workers and family alike - there is always some element of wishing the sufferer would be gone.  

Insightful healthcare workers recognize this "dark side" impulse as a natural one; and this recognition helps them to work through their own ambivalence about the suffering patient. More importantly, it also helps them to council members of the patient's family, who often have deep feelings of guilt because of the same kinds of ambivalent feelings. The prohibition against euthanasia and assisted suicide makes the bedside a "safe" place to work through these issues - we can recognize and deal with our darker impulses, knowing that, no matter what, we don't have the option of acting on them.

And working through such impulses is ultimately healthy.  By doing so, we learn to understand and live with the suffering of others; we learn compassion for the human condition; ultimately, we learn to be more accepting when it is our own turn to suffer.

But if there were an alternative, if we didn't really have to deal with watching our loved ones suffer, or with the feelings of frustration, anger and guilt their suffering caused within us, then wouldn't it be easy to simply to take advantage of that alternative? Over time, it would become difficult for us to understand why anybody would tolerate suffering (and why they would be so unfeeling as to expose the rest of us to the discomfort of having to watch them suffer, and to have to care for them while they selfishly did so), when there was such an obvious, painless and commonly-used alternative. After a while we would learn to apply this solution to more and more forms of suffering, and our tolerance for any form of suffering, real or perceived, would erode. Suffering individuals would no longer teach us compassion for the human condition; they would merely provoke disgust.

This is not just a prediction.  It has, you'll remember, happened before.

Inviting lawyers to the bedside

There's no way we'll ever tolerate physician-assisted suicide without "safeguards."  The legal safeguards, in fact, are the main reason proponents give as to why assisted suicide will never be abused. Consider what such laws will do, however. They will directly inject lawyers, for the first time on a routine basis, into the process of end-of-life care. And when we remind ourselves that the only other model we have for legal killing in our society (outside of warfare) is capital punishment, we get a flavor of what such legal wranglings might mean.  

Coming to terms with death is hard enough on everybody as it is.  Do we really want to add lawyers to the mix of family, friends, medical personnel and clergy at the bedside?  Do we really want to turn the process of dying into just another (particularly difficult) legal process?

The slippery slope

The slippery slope argument is dismissed out of hand by most in the end-of-life movement.  It simply doesn't hold water, they say.  It is illogical to argue that something as affirming of individual autonomy as assisted suicide can ever lead to the abuses of individuals by society. And if, in reply, one tries to describe to them how it already has happened in recent memory, they tend to become horribly indignant and shut off all conversation.  "If we can't discuss this without you calling me a Nazi, then we have nothing to talk about."

People in the end-of-life movement are not Nazis.  The vast majority are good, compassionate, well-meaning people who have the best interests of dying patients at heart. But if you examine the facts coldly and logically, and if you factor in the depth of our increasing economic crisis in healthcare, the slippery slope argument, I believe, becomes compelling.

Let's deal first with the Nazis.  The Nazis were obsessed with the purity of race, with removing all "imperfect" humans from the breeding pool. That was their ideology, and we don't have that ideology.

Yet, the evolution of the arguments advanced by the Germans to justify their actions sound eerily familiar.  Long before the Nazis came to power, German scholars were calling for legal euthanasia as a means of promoting mercy and personal choice in the face of intractable suffering, using language identical to the language we are hearing today.  This movement steadily gained steam, and during the economic crisis of post-World-War-I Germany it came to be advanced as a way of controlling spending on individuals who were seen as burdens to society.  The "science" of eugenics nicely added the imprimatur of the scientific community to the humanitarian and economic arguments made by proponents of euthanasia.  By the time the Nazis came to power, the groundwork had been laid for their handiwork.  It had been laid not by fiends, but by generally well-intentioned scientists, doctors, lawyers, and economists. To dismiss those events, out of hand, as irrelevant to our culture is just foolish.  

Also relevant to the slippery slope argument is the Dutch experience with euthanasia.  The Dutch have not actually legalized euthanasia, but have developed an official policy under which the laws forbidding euthanasia will not be enforced as long as certain guidelines are adhered to. These guidelines require intolerable suffering on the part of the patient that causes them to persistently request to be allowed to die; the patient must have a good understanding of what he or she is requesting; no other reasonable solutions can be apparent; and at least two physicians must concur that euthanasia is the only good choice.  

Recent reports on the Dutch experience have been mixed.  American proponents of assisted suicide see a shining example of the societal benefits of permitting end-of-life autonomy of choice.  Opponents see a series of terrible abuses (noting, specifically, an utter disregard of the prescribed guidelines).  To me, the most striking feature of the Dutch experience, and the most relevant to the slippery slope argument, is that thousands of cases of "active involuntary euthanasia" are reported to be occurring each year.  In other words, patients are being killed at the hands of their doctors and without their permission.  All, it is said, are leading insufferable existences, and all are being euthanized solely for humane reasons.

What do medical ethicists say about such a thing?  Not all agree, of course, but it turns out that it is fairly easy to derive an ethical argument in support of involuntary active euthanasia from the starting point of upholding individual autonomy.  It goes like this: the principle of autonomy demands that patients be allowed to refuse therapy; refusal of therapy is the ethical equivalent of voluntary euthanasia (as we have seen); since voluntary euthanasia is a right of individuals with intractable suffering, it follows that it would be unethical to withhold euthanasia from suffering individuals just because they are incapacitated and unable to give their permission. Hence, involuntary euthanasia is ethical for suffering patients who are unable to give their permission.  

Where this leaves us is at a place where others can decide for an individual what constitutes intractable suffering, and when that individual is incompetent to make such a determination for him or herself.  Where these "others" end up drawing the line on whether a person's existence is of value or whether a person is competent, of course, can be influenced by all sorts of external factors.

In Nazi Germany, those external factors included a belief in the purity of the Arian race, and that belief led to horrible excesses.  Again, we don't have that belief here.  

What we do have is an imperative to ration healthcare, which means that potentially beneficial care is going to have to be withheld from somebody, somewhere.  Can we be sure that, once we start down the road of allowing patients to choose death, we will be able to withstand our external influences, and stay our hands from ending the suffering of some who might not be so sure of their choice or who are incapable of making a choice - especially when, by so doing, we will make more healthcare available to others who could actually benefit from it?

I believe the slippery slope argument holds a lot of water.  

Erosion of the doctor-patient relationship

I don't need to say too much more about this.  A short vignette will suffice.

Vignette: Why is that doctor smiling?

Imagine yourself at age 75 in a hospital bed with a serious illness, but one that is potentially treatable with a lot of effort. Your doctor walks in, smiling.

If physician-assisted suicide and euthanasia are not available, you can be reasonably sure he's smiling with confidence. He thinks he can cure you, and his smile tells you so. You relax. You feel better already.

But what if assisted suicide and euthanasia are legal?  What would his smile mean then? He still might be smiling with confidence, of course.  But maybe he's smiling for another reason. Maybe it's that sheepish, somewhat sympathetic, ain't-life-a-pisser smile that can herald bad news. Maybe he's about to pull up a chair, slowly let his smile fade, and say, "Well, you know, things don't look so good this time, Charlie."  He'll pause, then let the smile return, "But the good news is, we can make it all pretty easy on you."

Or worse, he might not say anything.  He might offer some vague opinions, like "Well, Charlie, we're sitting on some pretty nasty blockages here.  But I've seen worse."  That smile again. "I'm real certain things are going to work out just fine. And all that pain and windedness?  Well, that's going away. Promise." Then he leaves.  And he leaves you guessing. Just how hard is he going to work to make you well, before he decides the other way is better?  

You've even heard - well, you've heard they don't always tell you beforehand.

It's hard to imagine anything more destructive to the trust between a doctor and a patient than knowing that your doctor, at some point, may shift from trying to cure you to trying to usher you into the next life as cheaply and painlessly as possible (by encouraging suicide, by offering euthanasia, or by simply doing the euthanasia because you're so incompetent you can't see it's the only thing to do).

If people want to commit suicide, and if the ethicists agree that assisted suicide is entirely okay, then let the ethicists do the assisting. I have relatively little to say against ethicist-assisted suicide. But leave the doctors out of it.

So what should we do about physician-assisted suicide?

We should not legalize physician-assisted suicide and euthanasia, and certainly not while we're covertly rationing healthcare.  The potential for abuse is simply too high. Institutionalizing and popularizing these procedures will carry too high a price for our society.  And the ultimate price we would pay, supposedly in the pursuit of individual autonomy, ironically, is a devaluing of the worth of the individual. This is indeed a particularly precious example of the corruptive nature of covert rationing.

Does foregoing assisted suicide mean we'll need to abandon our suffering patients? On the contrary, as we have seen, turning our backs on the "easy way" should cause us to redouble our efforts to find ways of relieving the physical and emotional suffering of patients approaching the end of their lives. We've already made a lot of progress in this area.  

But what about those rare cases where terminal patients really do have intractable pain despite all efforts, and are begging to be given final relief?  I concede that there may be times when assisting suicide is the only humane course of action.  In those rare cases, the physician may reasonably conclude that her fiduciary duty to the patient should cause her to take this action for the patient's benefit, despite the law and despite potential consequences. A substantial minority of American physicians admit to having taken such action on a patient's behalf at least once.  Whether you think these doctors are heroes or criminals, at least it can be said for them that they are taking a principled action, and are doing so at their own personal risk, on behalf of and in concert with their patient, to whom they owe a fiduciary duty to at least relieve suffering, if curing is impossible.

This sort of action, of course, depends on a trusting relationship between the doctor and the patient.  It is ironic that covert rationing, which is clearly one of the forces behind the push to legalize assisted suicide, is destroying the relationship between doctors and patients that makes such intimate, trust-based actions possible.

The end-of-life controversies - conclusion

The issues surrounding end-of-life medical care are of vital importance both to individuals and to society. Perhaps more than any of the other issues we have discussed in this book, the way we handle end-of-life care will determine what kind of a people we will become in the 21st century.

End-of-life activists like to remind us that they are fighting to preserve, at almost any cost, the autonomy of individuals at the end of their lives.  But even on its face, insisting on autonomy in end-of-life decisions presents something of a paradox.  For what is death if not the ultimate reminder that the right of self-determination is, at best, a temporary gift?

"Gift" may not even be the right word here. Perhaps a better word would be "necessity."  For the ideal of individual autonomy - an ideal I have celebrated and will continue to celebrate in this book as a founding principle of American society, as our preeminent ethical norm, and as an ideal that is well worth fighting to maintain - is ultimately not nearly the highest possible good.  Our reliance on individual autonomy is not some pinnacle of ethical thought, but is merely a palliative, a partial and inadequate (though necessary) compensation for having to live in an imperfect world.  So as we finally face our exit from this imperfect world, the ideal of individual autonomy necessarily loses much of its significance.

Giving the dying patient a sense of control over their last days is a humane thing to do, and we ought always to do it, to the extent we can do so without harming society.  But to throw all other considerations to the wind, to make the dying patient's autonomy the overriding concern that trumps all others, ignores reality, ignores other things the dying patient needs more than his autonomy, is harmful to society, and calls into question our real motives.

While giving the dying patient some sense of control may be important, it is not the most important thing at that time of life. Certainly we should optimize his autonomy within appropriate bounds, but instead of encouraging a hasty exit there are things we should be doing that really need to be done.  We should offer relief from physical and emotional pain, offer help in resolving remaining issues of family or personal conflict, and offer spiritual support. We should let the dying person know that he won't be abandoned, that we will be there for him until the end.  We should let him know that, because dying is part of the human condition we all share, the fact of his dying does not make him different from us; it makes him like us, and binds us together. We are embracing him, not culling him from the herd. It is by such an affirmation of that person's continuing (indeed, everlasting) importance, and not by coercing him (overtly or subliminally) to exercise false autonomy by taking the easy way out (if not for him, then for us), that we truly honor his value as an individual.  It's the ultimate acknowledgement of his true autonomy.

Covert rationing precludes any such trust-based end-of-life care. It destroys the trust between doctors and patients, and even between patients and loved ones. It makes any solution to end-of-life care that is dependent on mutual trust utterly impossible.  Covert rationing corrupts everything it touches.

Next - Covert rationing summarized