February 1, 2000

Economic Motives for Physician-Assisted Suicide

The debate about physician-assisted suicide is replete with concern over the role of economic factors. Justice Rehnquist, writing for a majority of the Supreme Court in Washington v. Glucksberg, noted the state's interest in protecting patients from "the real risk of subtle coercion and undue influence in end-of-life situations," particularly those patients "whose autonomy and well-being are already compromised by poverty." Rehnquist went on to object that, "[i]f physician-assisted suicide were permitted, many might resort to it to spare their families the substantial financial burden of end-of-life health-care costs." Justice Souter, in his concurrence, pointed out that "[p]hysicians, and their hospitals, have their own financial incentives, too, in this new age of managed care."

These concerns are shared by many scholars. The New York State Task Force on Life and the Law warns that "patients may be pressured to consent to euthanasia when their care is expensive or burdensome to others." Susan Wolf urges us to "consider the dangers of assisted suicide in the context of managed care." Nancy Osgood laments ageism in America which may lead older people to seek assisted suicide rather than become "an economic burden on younger members." John Kilner observes that, "if choosing death becomes a socially accepted alternative, then patients needing much care may begin to consider themselves selfish merely for choosing to live." "The very autonomy sought to be exercised [by permitting physician-assisted suicide] cannot be invoked if it is only allowed to be considered in a medical environment where the primary source of assisted suicide advice comes from physicians with economic interests that could objectively be at odds with those of the patient," states one student law review note entitled "Undue Economic Influence on Physician-Assisted Suicide." Another note objecting to physician-assisted suicide declares simply that, "[a]mong the many factors that influence America's health care decisions, money is the most invidious."

The economic objections to physician-assisted suicide fall into three categories:

First, it is feared that physicians and other health care providers, such as hospitals and managed care organizations, faced with financial incentives to reduce health care spending, will pressure patients to request assisted suicide. Managed care plans often are financed with employer self-insured funds or with premiums paid by employers (together, in most cases, with employees). The managed care plan has an incentive to hold down spending in either case: to save employers money or to retain a profit by spending less than the amount of premiums. Managed care plans, in turn, employ various methods to encourage physicians to limit spending on plan enrollees. These techniques range from profit-sharing bonuses and risk-sharing arrangements (in which, typically. a portion of the physician's fee is withheld and returned only upon satisfactory evidence of the physician's fiscal frugality) to capitation (in which the physician is paid a fixed amount per enrollee per month, making the physician's economic incentives equivalent to those of a premium-financed plan). Confronted with these financial pressures, physicians may turn to assisted suicide as a means of reducing the costs of caring for enrollees.

Physicians also may feel that they must represent the interests of society in encouraging patients to choose less costly alternatives. Physicians may see themselves as instruments of "bedside" health care rationing. They may favor assisted suicide, particularly for older patients, in line with the beliefs of those like Daniel Callahan who think that the elderly have enjoyed enough of the resources of society and should make way for the young.

Hospitals are under economic constraints similar to managed care plans. In some cases, the hospital actually may be part of a managed care plan. In other cases, such as under Medicare, the hospital may be paid a fixed amount for a patient regardless of how long the patient stays in the hospital or what services the patient receives. This may lead hospital administrators to encourage their medical staffs to recommend physician-assisted suicide to hospital in-patients.

The second type of economic objection to physician-assisted suicide focuses on the role of the patient's family. Families, it is feared, may pressure patients to choose assisted suicide to avoid spending money that the patient otherwise could leave to the family. Or, family members may exert pressure because they are spending too much of their own money.

Finally, even without overt pressure from others, patients may opt for assisted suicide to save money. They may feel it is their duty to their loved-ones. They may feel they owe it to society.

Given the likely economic impact of assisted suicide, these fears arguably are worth taking seriously. Emanuel and Battin estimate that legalizing physician-assisted suicide could save each year as much as $627 million in the United States. While, as they point out, this is less than .1 percent of total annual US health care spending, the savings for an individual health plan or provider institution could be substantial enough to cause them to exert pressure on patients, either directly or through patients' physicians or families. Emanuel and Battin calculate, for example, that a large managed care plan (with 1.7 million enrollees) would save $3.3 million a year if the expected number of patients (351) chose physician-assisted suicide. The economic impact on the patient's family is likely to be even more dramatic, particularly if the patient lacks health insurance. According to Emanuel and Battin, the average family of such a patient could save $20,000 if the patient chose physician-assisted suicide. Finally, studies, not surprisingly, show that terminally-ill patients already take the costs and burdens of their care into account in making end-of-life treatment decisions; they are likely to be even more sensitive to these considerations if they perceive physician-assisted suicide as a more attractive alternative to currently available ways of dying.

The fears that physicians and other health care providers, families and patients themselves may favor assisted suicide for economic reasons, therefore, seem real. The question, however, is whether or not they should be fears.

Let's consider the third category of concerns: that patients, on their own initiative and without pressure from others, may take financial considerations into account in choosing physician-assisted suicide. Is there something necessarily improper about this? Or, more to the point, is there something so improper about this that we ought to deny that person the right to do so lawfully, by making physician-assisted suicide illegal?

Are economic motives for physician-assisted suicide inherently unacceptable?
Suppose the patient choosing physician-assisted suicide is wealthy and fits whatever medical criteria are required to be a candidate. One motivation for her choice is that she wishes to leave her wealth to her family rather than to spend any more of it on her health care. But, apart from this consideration, she would not want to live anyway.

It is difficult to imagine that we would deny physician-assisted suicide to this person solely because she is taking economic considerations into account in making her decision. There is nothing inherently wrong in having an economic motive, among others, for one's behavior.

Suppose, instead, that the wealthy patient would want to go on living, but for her desire to leave her wealth to her family rather than spending any more of it on her health care. In other words, economic considerations are what tip the scales for this patient in favor of physician-assisted suicide. It is still difficult to accept that the patient's economic motivation alone should disqualify her from carrying out her wish. We may disagree with this person's decision. We may even question her competence in choosing to die in order to leave more money to her family when it already would receive a great deal of money even if she went on living. But a competent patient's right to autonomous decision-making undoubtedly extends this far.

Now suppose instead that the patient is poor, or at least significantly less well-off than the patient in the previous example. Unlike the wealthy patient for whom physician-assisted suicide may make no more difference than being able to leave another luxury automobile or two to her heirs, the poorer patient who goes on living faces the prospect of not being able to leave her family enough to live on decently.

This clearly is a more disturbing scenario, at least if we assume that the patient is poorer through no fault of her own. (Of course, that may not be the case: The patient may have less money because she gambled it away, or took expensive vacations, or chose to have a large family. Even then, we may feel sorry for the patient, just as we might feel sorry for the patient who was dying of lung cancer because she smoked cigarettes.) There is something morally wrong with someone being in such a situation. We ought to object to it and to a society that places people in such a predicament. We ought to work tirelessly to achieve a better social system. But, in the meantime, should we deny the poorer patient the ability to make her choice? Indeed, some might say that the poorer patient's ability to choose physician-assisted suicide is all the more valuable to her because of her predicament that, precisely because so much more is at stake for their families, it is more important for this option to be available to poorer patients than to richer ones.

The problem with this reasoning might seem to be that the poorer the patient, the less options that she has. If she is sufficiently poor, the patient may feel that she has no option but physician-assisted suicide, that her family's financial predicament is so dire that she has no real choice at all. In this case, we might object that, in contrast to the wealthy patient, the poorer patient's decision simply is not voluntary.

But consider the patient who chooses physician-assisted suicide to escape intractable pain, or indignity and loss of control, or simply the prospect of a lingering demise and who faces these conditions through no fault of her own. Like the poorer patient, this patient, too, faces a truly "tragic choice," to borrow a term from Calabresi and Bobbitt. Her dilemma moves us deeply. Her predicament, by depriving her of a viable alternative, may seem to deny her a voluntary choice. But does denying her the option of physician-assisted suicide improve her condition in any way?

The same seems true of denying physician-assisted suicide to the poorer patient.

The two types of patients - the one facing the Hobson's choice of unbearable suffering or death, the other the Scylla of death or the Charybdis of familial impoverishment - are in morally equivalent circumstances. One seeks to be free of oppressive pain, the other of economic oppression. The plight of the poorer patient profoundly affects us.

We redouble our efforts to create a more just society. We might even take up a collection. But allowing these patients to obtain physician-assisted suicide may, in the end, allow them to make the best of a bad situation.

If, nevertheless, we deny them this option, we can have only two reasons. First, we could take the position that economic constraints are fundamentally improper grounds for making this kind of decision. In the context of the poorer patient, as in the case of the wealthy patient, this position is unpersuasive. Second, we could object that by giving these patients a way out of their predicament - albeit a distasteful one — physician-assisted suicide would impair our efforts to achieve a more just society. For example, it could deflect us from research on better types of end-of-life care. But it seems unfair to force the poorer patient to endure in order to benefit future patients. In any event, it can be argued that permitting poorer patients to avail themselves of physician-assisted suicide for economic reasons and dramatizing their plight is the most effective way to promote social change.

If that is so, then there is no convincing reason why a patient who is acting completely on her own initiative, whether she be rich or poor, should be denied physician-assisted suicide because her decision turns, in whole or in part, on economic factors. If there remains a valid objection to economic motivations for physician-assisted suicide, it must stem from the concern that the patient is not acting completely on her own initiative but under pressure from others, from health care providers and managed care organizations, or from their families.
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