Correspondence

Potential Cost Savings from Legalizing Physician-Assisted Suicide

N Engl J Med 1998; 339:1789-1790December 10, 1998

Article

To the Editor:

I am troubled that in their examination of the potential cost savings from legalizing physician-assisted suicide, Emanuel and Battin (July 16 issue)1 relegate what I consider a central issue to an afterthought: the costs borne by individual patients and their families during protracted, terminal illnesses. Just as the nation's ability to spend one seventh of its aggregate wealth on health care is no solace to ordinary people who become seriously ill and face medical bills of tens or hundreds of thousands of dollars,2 savings may seem small on average but still be very important to the persons who might realize them. Although Emanuel and Battin acknowledge this, they fail to confront the next logical question: whether people should be allowed to preserve their financial resources by forgoing protracted, expensive treatment and choosing assisted suicide. Even universal health care coverage would not allow us to avoid answering this question. Custodial care is excluded from most insurance policies, and many real costs incurred by patients and families cannot be reduced to money. Furthermore, fitting these costs into an insurance framework risks medicalizing and depersonalizing the dying experience to an even greater extent than is already done.

Given this situation, Emanuel and Battin worry about what “would motivate families to pressure patients into requesting a physician's assistance with suicide.” I have an additional worry: that care givers and government will ignore the possibility that patients might voluntarily choose to spare themselves and their families the expense.3 Although competency, coercion, and the medical profession's role in decisions to end life are troubling problems meriting serious thought and discussion, I do not believe that one can sidestep the issue of cost merely by dismissing the aggregate savings as trivial. Therefore, I hope that future discussions of assisted suicide and cost will focus on individuals, as well as systems, and will explore the moral legitimacy of making a personal physical sacrifice for an equally personal financial benefit.

William M. Sage, M.D., J.D.
Columbia Law School, New York, NY 10027

3 References

1
Emanuel EJ, Battin MP. What are the potential cost savings from legalizing physician-assisted suicide? N Engl J Med 1998;339:167-172
Full Text | Web of Science | Medline

2
Glied S. Chronic condition: why health reform fails. Cambridge, Mass.: Harvard University Press, 1997.

3
Hardwig J. Is there a duty to die? Hastings Cent Rep 1997;27:34-42
Web of Science | Medline

To the Editor:

I am dismayed that the debate about physician-assisted suicide has deteriorated into a discussion of how much money it saves. The comment that Emanuel and Battin quote, “Less expensive is better,” is frightening, since it does not even include the qualification “as long as a certain level of quality is maintained.”

The preoccupation with health care costs is causing us to lose sight of what health care is all about. It is still about taking care of sick people. Although preventive care has a place, most of our time and effort — and consequently most of the health care dollar — is devoted to people with disease. This, of course, explains why the expenditures in the last months of life are disproportionately high. The persons most likely to die are the ones who are sickest, and the persons who are sickest receive the most medical care. Even the most dedicated proponents of preventive medicine find this justifiable when it is their mothers who have metastatic breast cancer.

If we as a society decide that we are spending too much money on the people who are the sickest, what reapportionment scheme should we use? For this contingency, I offer a “modest proposal”: abolish all medical care. This proposal has the virtue of immediately realizing the perfect health care savings, a full 100 percent; no other scheme can come even close under the “less expensive is better” criterion. Nor will the outcomes be all that radically different, except for the sickest persons, whom we will be dumping a priori in this reapportionment. Those with self-limited illness will by definition survive anyway. Nor would there be any point in squandering money on preventive measures, since the conditions being prevented would not be treated down the road anyway, thus making prevention the more expensive (i.e., undesirable) alternative.

If policy makers and society find this proposal too radical, an alternative method of reapportionment will have to be devised. But it would be wise for both policymakers and society to remember that it is not just dollars that are being reallocated; it is people's access to medical care.

Linda Jõe, M.D.
Tallinn EE0001, Estonia

Author/Editor Response

The authors reply:

To the Editor: “Your money or your life?” This is the macabre question of the highwayman. Dr. Sage fears that it will also be seriously debated in civilized society. We are very much aware that terminal illness can have a substantial adverse effect on families, especially in a system that fails to provide adequate health insurance for all. Every individual and family must determine whether certain goods and activities are worth their financial cost. Choices such as whether to go to a state university or spend more for an elite private college, save for retirement or buy a fancier home, buy a new car or send a child to an enrichment program, and donate money to charity or go to the movies constitute the fabric of life. However, making these choices is not the same as being forced to make the choice of saving personal money for one's family by opting for physician-assisted suicide or leading the family into bankruptcy.

The highwayman's menacing threat does not constitute a reasonable choice, and it is one that society cannot allow — not in the case of physician-assisted suicide and not in the case of other life-and-death choices. Of course, medical costs need to be reduced, health care resources need to be allocated wisely, and, most believe, real health benefits will need to be forgone. But making such policy choices is much different from asking people — nay, each dying person — to decide whether they value their own lives or their own money more. Any society that forced each person to confront such a choice would contribute to making life “nasty, brutish, and short.”

Dr. Jõe's “modest proposal” is hardly new. It first occurs in Plato's Republic, in which Socrates asserts that the few physicians permitted in the ideal state should not coddle people with chronic illnesses; these people should return to work and either survive on their own or die. We certainly do not advocate or endorse such a proposal. Indeed, part of our motivation in writing this and other articles has been to counter the views of those who believe the health care system's financial woes can be solved on the backs of the dying.1 Our article was an effort to debunk the very proposal Dr. Jõe makes. Although, as we said in our article, one of us favors legalization of physician-assisted suicide and the other opposes it, we both have long been committed to improving the care of patients at the end of life.2 This should be a primary objective of our health care system.

Ezekiel J. Emanuel, M.D., Ph.D.
Dana–Farber Cancer Institute, Boston, MA 02115

Margaret P. Battin, Ph.D.
University of Utah School of Medicine, Salt Lake City, UT 84112

2 References