guthealthcare.com

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?