Would financial motivations encourage insurance companies, health care providers, and patients to seek euthanasia and physician-assisted suicide if those options were legally available?
General Reference (not clearly pro or con)
The Organisation for Economic Co-operation and Development (OECD), in their "OECD Health Data 2012: How Does the United States Compare" report, available at www.oecd.org, stated:
"Health spending accounted for 17.6% of GDP in the United States in 2010, down slightly from 2009 (17.7%) and by far the highest share in the OECD, and a full eight percentage points higher than the OECD average of 9.5%. Following the United States were the Netherlands (at 12.0% of GDP), and France and Germany (both at 11.6% of GDP).
The United States spent 8233 USD on health per capita in 2010, two-and-a-half times more than the OECD average of 3268 USD (adjusted for purchasing power parity). Following the United States were Norway and Switzerland which spent over 5250 USD per capita. Americans spent more than twice as much as relatively rich European countries such as France, Sweden and the United Kingdom.
Total health spending in the United States increased in real terms by 4.3% per year on average between 2000 and 2009, but this growth rate has slowed significantly to 2.7% between 2009 and 2010.
In most countries, health spending is largely financed out of taxes or social security contributions, with private insurance or 'out-of-pocket' payments playing a significant but secondary role. The United States which, together with Mexico and Chile, are the only OECD countries where less than 50% of health spending is publicly financed. The public share of health expenditure in the United States was 48.2% in 2010, much lower than the OECD average of 72.2%.
However, the overall level of health spending in the United States is so high that public (i.e. government) spending on health per capita is still greater than in all other OECD countries, except Norway and the Netherlands. Public spending on health in the United States has been growing more rapidly than private spending since 1990, largely due to expansions in coverage."
Would financial motivations encourage insurance companies, health care providers, and patients to seek euthanasia and physician-assisted suicide if those options were legally available?
The New York State Department of Health in their Apr. 2011 report "When Death Is Sought," available on www.health.ny.gov, stated:
"Under any new system of health care delivery, as at present, it will be far less costly to give a lethal injection than to care for a patient throughout the dying process.
The current debate about medical futility reflects, in part, the extent to which the cost of treatment is viewed as relevant to decisions at the bedside. Some physicians have argued that they should determine when the benefits of treatment are too low to justify the cost in order to allocate health care resources. To date, the futility debate has focused on certain aggressive treatments, such as cardiopulmonary resuscitation, or on continued treatment for certain patients, such as those who are permanently unconscious. But once a decision is made not to pursue cure or treatment, and assisted suicide and euthanasia are available, the economic logic will be inescapable. The care provided to dying or very ill patients, not just their treatment, is expensive and demanding for health care professionals. The extra weeks or months of caring for patients who do not opt for assisted suicide or euthanasia will seem all the more 'futile' and costly."
Rita Marker, JD, Executive Director, and Kathi Hamlon, Policy Analyst, both of the of the International Task Force on Euthanasia and Assisted Suicide, wrote in a Jan. 2010 article titled "Euthanasia and Assisted Suicide: Frequently Asked Questions" on InternationalTaskForce.org:
"Perhaps one of the most important developments in recent years is the increasing emphasis placed on health care providers to contain costs. In such a climate, euthanasia or assisted suicide certainly could become a means of cost containment...
Savings to governments could become a consideration. Drugs for assisted suicide cost about $75 to $100, making them far less expensive than providing medical care. This could fill the void from cutbacks for treatment and care with the 'treatment' of death...
Legalized euthanasia or assisted suicide raises the potential for a profoundly dangerous situation in which the 'choice' of assisted suicide or euthanasia is the only affordable option for some people."
Care Not Killing posted the following in their Jan. 21, 2009 "Euthanasia and Assisted Suicide - Q and A (Shorter version)," available at www.carenotkilling.org.uk:
"If the law is ever changed to allow so called 'assisted dying' it is inevitable that economic pressure will be brought to bear on people, openly or more likely very subtly, to request early death in order to save money for the use of relatives, society or a health service short of the resources it needs. Killing is very cost effective – it does not cost much for an ampoule of barbiturate. That is why we need to promote care, not killing, and hold onto laws which protect vulnerable people."
Paul B. Young, MD, MA, pediatrician in Wisconsin, stated the following in his Apr. 8, 2008 testimony for Wisconsin Right to Life, "Against Physician Assisted Suicide," available at www.wrtl.org:
"The single greatest pressure on healthcare today is financial. As we seek to grapple
with the staggering costs of healthcare, we need to avoid undermining the very ethical
principles that promote good patient care. If we allow physician assisted suicide, we
may find out that we have effectively limited our approach to the palliation of chronic
illness. Unfortunately, it is cheaper to help a patient to die than to provide good end of
life care. Physician assisted suicide could encourage a patient to die as a 'duty' to his
or her family, in the face of financial pressure. Likewise doctors could find their end
of life care options curtailed by third party payers, or offered economic incentive to
allow a suicide. As society ages, this could become a national tragedy."
Porter County Right to Life wrote on their 2006 "Euthanasia" page, available at www.pcrtl.org/euthanasia:
"With the increasing emphasis placed on health care providers to contain costs, euthanasia could certainly become a means of cost containment.
In the U.S., thousands of people have no medical insurance; studies have shown that the poor and minorities are not given access to available pain control, and managed-care facilities are offering physicians cash bonuses if they don’t provide care for patients.
With greater and greater emphasis being placed on managed care, many doctors are at financial risk when they provide treatment for their patients.
Legalized euthanasia raises the potential for a profoundly dangerous situation in which doctors could find themselves far better off financially if a seriously ill or disabled person 'chooses' to die rather than receive long-term care.
Savings to the government may also become a consideration. This could take place if governments cut back on paying for treatment and care and replace them with the 'treatment' of death."
Marilyn Golden, Policy Analyst for the Disability Rights Education & Defense Fund, in a Nov. 17, 2005 article titled "Why Assisted Suicide Must Not Be Legalized," available at www.dredf.org, wrote:
"Perhaps the most significant problem is the deadly mix between assisted suicide and profit-driven managed health care. Again and again, health maintenance organizations (HMOs) and managed care bureaucracies have overruled physicians' treatment decisions. These actions have sometimes hastened patients' deaths. The cost of the lethal medication generally used for assisted suicide is about $35 to $50, far cheaper than the cost of treatment for most long-term medical conditions. The incentive to save money by denying treatment already poses a significant danger. This danger would be far greater if assisted suicide is legal."
Maxwell J. Mehlman, JD, Arthur E. Petersilge Professor of Law at the Case Western Reserve University School of Medicine, wrote in his Feb. 1, 2000 article "Economic Motives for Physician-Assisted Suicide," available at www.thedoctorwilseeyounow.com:
"...[I]t 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."
N. Gregory Hamilton, MD, psychiatrist, is quoted in a May 20, 1998 Hospitals & Health Networks article, "Bitter Ends in Oregon," written by reporter Mark O'Keefe, available at www.hhnmag.com, as having said:
"I don't think this is a conspiracy by the HMOs... But the fact is that the arrangement some HMOs are proposing will pressure people, whether that is their intention or not. A $1,000 cap on in-home care for the terminally ill puts the weak and vulnerable in a bind."
George Runner, Republican California State Senator, wrote in an Apr. 4, 1999 opinion piece titled "Valley Perspective; Suicide Is Not a Treatment for Anything; The 'Right to Die' Plus Managed Care is a Dangerous Combination," that appeared in the Los Angeles Times:
"Health Maintenance Organizations (HMOs) may attempt to reduce health care costs by refusing to pay for expensive or 'unnecessary' procedures. What better way to cut costs than on those people who won't be here much longer anyway?
If this sounds farfetched, consider the following: While discussing the recently passed Oregon right-to-die law, a spokesperson for QualMed Oregon Health Plan confirmed that it would cover lethal medications 'as a prescription' while its 'value option' plan limits hospice care to $1,000...
Just think of all the money that could be saved by HMOs if they spared the expense of treating AIDS patients or the disabled, many of whom could easily be classified as terminally ill..."
Wesley Smith, JD, Senior Fellow in Human Rights and Bioethics at the Discovery Institute, wrote in his 1997 book Forced Exit:
"Consider the intense pressure to cut costs in connection with legalized euthanasia. If killing patients because they are seriously ill or disabled becomes a legitimate method of 'treatment,' patients who require depth of care will be endangered. Remember, for H.M.O.s (health-maintenance organizations), profits come not through providing services but from limiting costs, meaning reducing services in some cases. Imagine the money that could be saved - and thus profits earned - by H.M.O.s by not treating cancer patients because they 'choose' instead to be killed; in not treating AIDS patients because they choose instead to be killed; in not treating M.S. pateints because they 'choose' instead to be killed; in not treating quadriplegic patients because they 'choose' instead to be killed."
Compassion & Choices, in a fact sheet titled "Facts about Death with Dignity & Access to Medical Care" available at www.compassionandchoices.org (accessed Dec. 12, 2012), wrote:
"Studies show that HMOs have no financial incentive to pressure terminal patients to end their lives because there are no cost savings.
It is well documented that the legal option to choose aid-in-dying is not related to finances. End of life choices are relevant only AFTER all curative or other treatments have been tried. Aid in dying comes within the hospice setting, which is paid by Medicare, not HMOs. When a patient enters hospice, an HMO turns the care over to Medicare to reimburse the hospice. The HMO is essentially out of the finances. HMOs play a small role in that setting, and have no financial incentive to influence patient choices."
Martin Levin, JD, MPH, MTS, Special Counsel for the Robert F. Kennedy Center for Justice and Human Rights, and Senior Counsel for Levin, Papantonio, Thomas, Mitchell, Rafferty & Proctor, in his article "Physician-Assisted Suicide: Legality and Morality," available at www.levinlaw.com (accessed Dec. 13, 2012), wrote:
"What is absolutely incredible to me is that someone would honestly argue that we should consider the cost savings to America by killing, or assisting in the suicide, of human beings. It seems almost unfathomable. However, even if we were to consider these figures, the savings only total approximately $10,000 per assisted suicide victim. The total savings of approximately $627 million is less than one percent of the total United States health care expenditures. The reason this figure is so low is because an extremely small percentage of Americans receiving health care would qualify for physician-assisted suicide. We are not talking about the withholding or withdrawing of life-sustaining procedures. This is already legal, and widely utilized. We are talking about allowing a competent adult suffering from an incurable illness with less than six months of life to seek the assistance of a physician in actively ending the patient’s life. This number makes up less than 1/3 of 1% of Americans each year, and those who do qualify, and who choose to die by assisted suicide, generally end their lives approximately three weeks before their natural death would have occurred."
The Death with Dignity National Center (DDNC) wrote in their 2012 "Frequently Asked Questions about Death with Dignity," available at www.deathwithdignity.org:
"No one is encouraged to use the [Oregon and Washington Death with Dignity] law. To date, persons who have chosen to use the law have been well educated, have had excellent health care, have had good insurance, have had access to hospice and have been well supported financially, emotionally and physically. Absolutely no HMO or insurance company participates in this process."
Ezekiel Emanuel, MD, Chair of the Department of Clinical Bioethics at the Warren G. Magnuson Clinical Center, National Institutes of Health, and Margaret Battin, MD, Distinguished Professor of Philosophy and Adjunct Professor of Internal Medicine, wrote in their July 16, 1998 article titled "What Are the Potential Cost Savings from Legalizing Physician-Assisted Suicide?," published in the New England Journal of Medicine:
"One large managed-care plan currently enrolls approximately 1.7 million adults and has an annual budget of almost $4.5 billion. In 1995, approximately 13,000 of the enrolled adults died, including 3,800 who died of cancer. Over the last six months of life, the mean cost for patients enrolled in this managed-care plan who died of breast cancer was $21,329 (in 1995 dollars), with about $9,500 spent in the last month of life. Assuming that 2.7 percent of the patients who died would have chosen physician-assisted suicide (351 patients), forgoing an average of four weeks of life at an average savings of $9,500, the managed-care plan's expenditures would have been reduced by $3.3 million, or less than 0.08 percent of its total budget. For other managed-care plans that tend to have higher proportions of young, healthy patients with lower death rates, the absolute and relative savings are likely to be even smaller...
The estimated cost savings from permitting physician-assisted suicide are lower than many people expect...
People overestimate the number of Americans who die each year. Less than 1 percent of Americans die each year. Of these, many would be unable or ineligible to request a physician's assistance with suicide, even if it were legalized: newborns with serious birth defects, minors, victims of trauma, persons who die suddenly from myocardial infarctions or strokes, and patients with dementia. More important, if Americans were to choose physician-assisted suicide at the same rate as the Dutch choose euthanasia, only 0.027 percent of Americans might choose physician-assisted suicide if it were legalized...
Physician-assisted suicide is not likely to save substantial amounts of money in absolute or relative terms, either for particular institutions or for the nation as a whole."
The American Association of Health Plans spokesman is quoted in a May 20, 1998 Hospitals & Health Networks article, "Bitter Ends in Oregon," written by reporter Mark O'Keefe, available at www.hhnmag.com, as having said:
"[The idea that insurance companies would promote assisted suicide] is abhorrent, repugnant, and detestable. It's just someone's conjecture, and that conjecture is really an insult."
Merrill Matthews, PhD, Director of the Center for Health Policy Studies at the National Center for Policy Analysis, wrote in his article, "Would Physician-Assisted Suicide Save the Healthcare System Money?" that appeared in the 1998 book Physician Assisted Suicide: Expanding the Debate:
"Would Physician-Assisted Suicide Save Money?
The answer to the question seems almost certainly no... The primary reason is that the number of people seeking physician-assisted suicide and being granted that asssistance is extremely small...
Most requests for physician assistance come in the last month, or even the last days of life, which would drastically reduce the actual amount of money saved. For example, in the survey of Dutch physicians, 64 percent said they had shortened a patient's life by less than twenty-four hours, and in 16 percent it was shortened less than a week.
...Even though the various elements that make up the American healthcare system are becoming more circumspect in ensuring that money is not wasted, the cap that marks a zero-sum healthcare system is largely absent in the United States... Considering the way we finance healthcare in the United States, it would be hard to make a case that there is a financial imperative compelling us to adopt physician-assisted suicide in an effort to save money so that others could benefit..."
Laurence Tribe, JD, Professor at Harvard Law School and expert on health law, was quoted in an Apr. 7, 1996 article titled "The Right to Suicide, Some Worry, Could Evolve Into a Duty to Die," published in the New York Times:
"There are far greater economic pressures on patients who must maintain expensive life-sustaining treatment than on those forced to endure painful, drawn-out illnesses where no such therapy is available...and there has been no evidence that people in those situations are being pushed to withdraw treatment because of the high cost."
Ross Douthat, Op-Ed Columnist for the New York Times, wrote in a Sep. 6, 2009 New York Times article titled "A More Perfect Death":
"...the American way of death is different. Our move toward physician-assisted suicide springs from the same quest for mastery over mortality that leads us to spend nearly twice as much on health care as any other developed nation. And our instincts run so strongly toward unlimited spending that it’s much easier to imagine the government going bankrupt paying for extreme life-saving procedures than it is to imagine a suddenly cost-conscious bureaucracy pressuring doctors to administer lethal overdoses."
The United States 9th Circuit Court of Appeals stated in its 1996 opinion from Compassion in Dying v. Washington :
"One of the majority's [the majority ruling overturned in this decision] prime arguments is that the statute [outlawing physician-assisted suicide] is necessary to protect 'the poor and minorities from exploitation,' -- in other words, to protect the disadvantaged from becoming the victims of assisted suicide. This rationale simply recycles one of the more disingenuous and fallacious arguments raised in opposition to the legalization of abortion. It is equally meretricious here. In fact, as with abortion, there is far more reason to raise the opposite concern: the concern that the poor and the minorities, who have historically received the least adequate health care, will not be afforded a fair opportunity to obtain the medical assistance to which they are entitled -- the assistance that would allow them to end their lives with a measure of dignity. The argument that disadvantaged persons will receive more medical services than the remainder of the population in one, and only one, area -- assisted suicide -- is ludicrous on its face. So, too, is the argument that the poor and the minorities will rush to volunteer for physician-assisted suicide because of their inability to secure adequate medical treatment...
We would be inclined to agree that the country's refusal to provide universal health care, and the concomitant suffering so many Americans are forced to undergo, demonstrates a serious flaw in our national values... On the other hand, we are certainly not obligated to pile injury upon injury by holding that all of our citizens may be subjected to the prospect of needless pain, suffering, and degradation at the end of their lives...because of our concern over Congress' failure to provide government-insured health care..."
[Editors Note: This opinion was later overturned by the US Supreme Court in Washington v. Glucksberg]