Ethicist-Assisted Suicide

September 8th, 2008 by DrRich

In a previous post, DrRich attempted to satirize the lame attempts of certain healthcare payers to “inform” certain of their covered lives that, among all the wonderful options available to them under their truly comprehensive health plans, the medical service of physician-assisted suicide would be compassionately offered and cheerfully paid for. (Note to the policy experts who direct politically-acceptable healthcare terminology:  Is the term “covered lives” even appropriate any more when we’re finally dabbling in the realm of covered deaths?)  DrRich even offered, thoughtfully as usual, some free though invaluable advice to payers on how they ought to go about marketing assisted suicide as a cost-saving strategy, and to do so in a far more sensitive and less ham-fisted way than they have managed so far.*

If the mark of good satire is that at least some readers will have difficulty discerning whether the satirist is serious or not, then DrRich is feeling genuinely Jonathan Swiftian today.  For, while David Hamilton of BNET seems to get the concept of satire, some of his readers (”I can’t believe what I just read. This is sick.”) do not.  This is not the first time DrRich has made unfortunate impressions upon readers through his (possibly inept) use of irony.  It will certainly not be the last.

But assisted suicide being such an important and ethically charged topic, DrRich feels obligated to clear things up once and for all. So what follows is DrRich’s honest assessment of the advisability of physician-assisted suicide, in which he will attempt to forgo entirely any satire or irony (though he admits to having great trouble in controlling his sarcasm).

DrRich believes that physician-assisted suicide is a very, very bad idea.  He has two major reasons for this belief.  On a purely practical realm, embracing and systematizing physician-assisted suicide under any healthcare system that is actively engaged in rationing (whether overtly or covertly) will necessarily lead to horrific abuses of the practice.  DrRich attempted to touch upon some of these entirely predictable outcomes of such a policy in his previous post.  For other negative outcomes that are likely or at least possible, you can either use your imagination, or read the history of Europe in the 20th century.

His second objection to physician-assisted suicide is based on ethics. DrRich admits to being on shaky ground here because: a) he is not formally trained in ethics, and b) it appears for all the world that formally trained ethicists have universally concluded that physician-assisted suicide is perfectly OK in every way.

Debating with modern medical ethicists, at least if you are merely such a one as DrRich, is a losing proposition.  This is not because ethicists are intellectually (or even ethically) superior, but rather because they are adept in couching their arguments in arcane twists of logic and webs of jargon that make their arguments difficult if not impossible for the uninitiated to follow.  This technique, of course, places laypeople like DrRich in the position of having to accept the ethical bottom line without really understanding how the bottom line was reached. It reduces medical ethicists to a priesthood, and medical ethics to received knowledge.

But DrRich maintains that advancing unintelligible ethical arguments is, well, unethical.

So DrRich will now present his understanding of the chain of logic by which modern ethicists justify physician-assisted suicide - and its close cousin, euthanasia.  (If any of you actual ethicists out there object to this analysis, and can explain where DrRich is wrong in clear language, DrRich will be all ears. Otherwise, you can pound salt.)

Point 1: Our society has already decided that the autonomy of the individual patient is the overriding ethical consideration in making end-of-life decisions. We made this determination when we decided that a patient has a right to refuse medical treatment even if that treatment is very likely to save their life.  Therefore, we have already firmly decided that passive euthanasia - letting nature take its course - is ethical.

Point 2: There is no ethical distinction between passive euthanasia and active euthanasia.  Whether we let death occur by withholding effective medical care, or by actually doing something to help death along a bit, we’re taking an action that hastens death either way. Ethically, both of these actions are equivalent. So, once we decide that individual autonomy is the overriding concern, we must also allow for active euthanasia when a patient wishes it.

Point 3: Once active euthanasia is deemed ethical, there can be no further ethical objection to the lesser act of physician-assisted suicide.  If it is ethical for a doctor him/herself to bring on the death of a patient who requests it, there can be no objection to doctors preparing the suicide machine and handing the patient the switch.

The striking thing here (to DrRich, at least) is that in establishing the ethical case for physician-assisted suicide, we necessarily also establish the ethical case for physician-provided euthanasia. Whether the patient says, “Help me to take my own life,” or “Take my life for me,” modern medical ethics supports the physician who replies, “Roll up your sleeve.”

For those who still don’t see a problem, DrRich refers you to the Dutch system, where the rules permit both physician-assisted suicide and active euthanasia for patients who request it, in full accordance with modern medical ethics. Reports on the results of the Dutch system (reports which both sides have used to bolster their respective opinions on either the glories or the travesties of such a system) do point out one striking finding - hundreds of times each year, acts of involuntary euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission. All these patients, it is claimed, are being euthanized for entirely humane reasons.

What do our friends the medical ethicists have to say about involuntary euthanasia? Well, it turns out that it’s OK with many if not most of them. Ethicists don’t like to tell us that their chain of logic doesn’t end with Point 3.  But once we make the principle of individual autonomy the overriding consideration in determining end-of-life ethical issues, the same chain of logic takes us directly to Point 4.

Point 4: Since honoring the autonomy of the individual makes voluntary euthanasia available for patients with intractable suffering, it would be unethical to withhold the same benefit from suffering patients who are too incapacitated to give their permission. Their incapacity should not restrict them from a good that is available to capable patients.  To fulfill this right, the boon of euthanasia can and must be performed, without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much - that is, involuntary euthanasia is also ethical.

This conclusion, of course, leaves us in a place where others (i.e., “reasonable people” like doctors) can decide for an individual what constitutes intractable suffering, and further, can decide when such an individual is simply too incompetent to know that euthanasia is the only thing to do. Some of you, of course (hello, ethicists!) think this is just a fine idea.  Most apologists for the Dutch system apparently do, for instance.

DrRich maintains that under a system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (insurers and the government) who determine their professional viability, and where the payers are under extreme pressure to reduce cost, and have already displayed in numerous ways their willingness to permit suffering and death among their subscribers in order to do so, then opening the door for physician-assisted suicide (let alone physician-administered euthanasia, whether the patient requests it or not), would lead to horrible abuses, and would ultimately serve to undermine our civil society.  DrRich is too politically correct to use the “other” N-word, but he will take this opportunity to remind his readers that such a thing has already happened, in what had been perhaps the world’s most cultured and educated society, during the last 100 years.

DrRich believes that the principle of individual autonomy is vitally important, and indeed it is the foundation of American culture. However, no single ethical principle, no matter how important, can be allowed to overrule all other ethical principles in all other circumstances.  Ethical principles are often in conflict, creating what is called an ethical dilemma. And (DrRich humbly submits) it is supposed to be the job of ethicists to help us work through those ethical dilemmas, to find the right balance between competing principles, and not simply to declare that no dilemma actually exists, because ethical principle X is the only one we need to pay attention to.

Individual autonomy is critically important, but in no other aspect of our culture do we let it absolutely rule. The autonomy of individuals needs to be checked, and we indeed limit it.  The reason we have laws (supposedly) is to make sure that the behavior of individuals who have accrued power  (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state) does not abrogate the rights of other individuals, and to make sure that individuals acting in their own interests do not create too high a cost for our society as a whole.  Indeed, most of the political fights we have - between Democrats and Republicans, liberals and conservatives - are to determine where best to place those limits, on individuals and on the collective, to best encourage a robust society that honors individual autonomy but that also encourages reasonably equal opportunity.  The main purpose of our public discourse, then, is to find the right balance between the rights and needs of individuals and the rights and needs of society as a whole.

So for ethicists to say, “Individual autonomy is all there is to it, and we have no choice but to follow that principle to wherever it may lead us,” is not only completely irresponsible and dangerous, it also flies in the face of our culture’s history and our everyday experience.  The cost to society not only should but must be taken into account as we consider institutionalizing physician-assisted suicide (let alone voluntary or involuntary euthanasia).  In DrRich’s opinion, ethicists who argue that we need not consider the cost to society in making end-of-life policy have declared themselves unworthy of the title and they ought to be completely ignored.

The cost to our society of institutionalizing and systematizing physician-assisted suicide, especially while we are still covertly rationing healthcare, would be severe and potentially lethal.  We simply should not do it, and we should fight efforts to make it so.

If people want to commit suicide and if medical ethicists insist that assisted suicide is OK, then let the ethicists do the assisting. DrRich has relatively little to say against ethicist-assisted suicide. But, at least as long as covert rationing is the chief operating paradigm of the American healthcare system, for the love of God keep the doctors out of it.

*Despite the clear value of this advice, DrRich still awaits his first “thank you” from Aetna or United HealthGroup or even the Oregon Health Plan.  This shows us once again that, unless they’ve paid expensive consultants a few hundred thousand dollars for it, big companies and big bureaucracies are utterly incapable of recognizing even obvious truths, truths that any of their middle managers could usually give them for free.

Posted in Medical ethics | 6 Comments »

The New Dutch Healthcare System

September 7th, 2007 by DrRich

Jason Shafrin at the Healthcare Economist has posted an excellent analysis this morning of the new Dutch healthcare system, also described yesterday in the Wall Street Journal.

The three operating principles of the Dutch system are these:

1) All individuals must purchase health insurance on the private market.
2) Health insurance companies must insure anyone who applies.
3) The insurers, while charging whatever they want for insurance premiums, are in active competition for subscribers.

There are, of course, details. But thanks to the Healthcare Economist (who presents a thorough summary of the innovative Dutch system, along with the usual insightful analysis of its advantages and potential pitfalls), DrRich has the luxury of limiting his comments to the Real Question, the Real Question being: How does the Dutch system account for healthcare rationing?

Healthcare rationing occurs when some centralized agency makes decisions regarding the distribution of available healthcare resources, such that, given a group of individuals who would probably benefit from certain healthcare services, at least some will not be permitted to receive those services.

Any time we create a centralized pool of money from which all healthcare services must be paid, some degree of rationing must occur. This is because the centralized pool of money, even if it is very large, is nonetheless limited, whereas the amount of money we could spend buying every bit of potentially worthwhile healthcare for every person who might benefit is fundamentally unlimited.

The only way to avoid any rationing whatsoever would be for individuals to pay for all of their own healthcare out of pocket. This way, any limitations in healthcare services would be determined by the individual, and not arbitrarily by some outside agency. (DrRich stipulates that such a system - where everybody simply pays for their own healthcare like they pay for their own housing or food - is not feasible. This is why he perseverates on the question of HOW we do the subsequently necessary rationing - that is, openly or covertly.)

The Dutch system does not avoid centralized pools of money from which healthcare services are paid, and so cannot avoid rationing.

But it does introduce an intriguing feature that might render the necessary rationing less destructive to individuals and to society than the kind of covert rationing we have in the US, or the kind of somewhat-less-covert rationing common in countries that have single-payer systems.

Under the new Dutch system, individuals are making the health insurance purchasing decisions themselves, and they have a choice among insurance companies. Individual Dutch citizens a) have suddenly become the customers of the insurance companies, and b) have the power to take their insurance premiums elsewhere if they don’t like the offerings of their present insurer.

This arrangement is radically different from what we have in the rest of the world, the US included - under the Dutch system, insurance companies are forced to compete with one another for the business of individual citizens.

Furthermore, the competition will be based not just on cost, but on value. That is, what do you get for your money? As always, there will be limits on which healthcare services are covered (in other words, there will indeed be rationing of available services). But the need to compete on the basis of value, ideally, will eventually force insurance companies to be more forthright on what those limits are. Individuals could then choose their health insurance based not only on the cost of premiums, but also on the various rationing features of available insurance products. Call it “competitive rationing.”

Competitive rationing will require insurance companies to attempt to discover the “perfect” balance between cost and services. Since not all individual purchasers will have the same set of values in this regard, a range of insurance products will have to evolve to meet the needs and desires of different customers.

So in theory, at least, the Dutch system has much promise. It doesn’t eliminate rationing, but it has the potential of bringing it out into the light, limiting it as much as possible, and rendering it far more equitable than either the covert rationing we have in the US, or the arbitrary, heavy-handed, centralized rationing we see in single-payer systems around the world.

Unfortunately, we can already see how the Dutch system is likely to fall apart. The problem stems from the system’s first two operating principles:

1) All individuals must purchase health insurance on the private market.
2) Health insurance companies must insure anyone who applies.

Competitive rationing, as DrRich conceives it, depends wholly on the competition that occurs in free markets. But in a system where every buyer must buy insurance, and every insurer must sell to anybody who applies, free markets cannot exist.

The only way to make these two operating principles feasible is to provide subsidies to the insurance companies in order to underwrite the cost of mandated coverage for those who are too old, or sick, or poor to pay for it themselves. Accordingly, the Dutch government has done just that. DrRich isn’t saying the government doesn’t need to do this; there’s no other way he can think of to provide mandated insurance to those who can’t pay for it. But the bottom line is that the Dutch system simply does not create free markets. It can’t.

We can already see where this will lead. The government will pay for a larger and larger chunk of Dutch healthcare, and if it hasn’t already, will begin dictating behaviors within the healthcare system. It will have to (to protect the investment of the taxpayer). As a direct result, the rationing decisions in the Dutch healthcare system will necessarily become centralized once again. To avoid having to admit that it is making rationing decisions, the government will attempt to keep those decisions and their execution as covert as possible.

The guru of the Dutch system is Professor Alain Enthoven of Stanford University. Professor E is best known as the father of “managed competition,” which was the driving idea behind the Clinton’s attempt to reform American healthcare in the early 1990’s. The Dutch system is, in fact, the first actual implementation of managed competition.

The major difference between what the Clintons proposed and what the Dutch have actually implemented, as far as DrRich is concerned, is that the Clintons were more forward looking than the Dutch. They saw exactly what sort of end-game was destined for “managed competition,” and went right to the bottom line. Accordingly they presented to the American people an appallingly massive book of rules and regulations for the centralized control of our healthcare system (read: for covertly rationing healthcare). It scared the hell out of us, and we said no. (We opted instead for a more gradual pathway to an appalling system of covert rationing, one administered by both the government and private insurers.)

While what the Dutch have is in many ways a good idea, they will almost certainly also end up with a healthcare system that is largely centrally controlled. And unless the question of rationing is addressed openly and forthrightly, they, like us, will eventually fall under a system where the necessary rationing is done covertly.

God bless them for their attempt, though. It is a brave one.

Posted in General Rationing Issues | No Comments »