Copyright (c) 1999 First Things 94 (June/July 1999): 14-16.
It is the unfortunate nature of man that financial imperatives often supersede important moral and ethical principles. We often tolerate or even celebrate inherently unethical and immoral actions as long as they make a buck.
Simply put, mammon has the power to distort moral intuitions. Take the issue of assisted suicide. Opponents of legalization warn that if killing is ever deemed a legitimate medical practice, the ultimate driving force toward hastened death will not be "choice" but money. Yes, legalized assisted suicide would begin primarily as a phenomenon of white, upper–middle–class people—the types who are typically the most supportive of legalization. But when a doctor killing his patient becomes an ordinary affair, assisted suicide could be seen as an easy way to cut medical costs, thereby increasing profits for HMOs while reducing financial burdens on taxpayers who pay for government health care programs and families who care for ill and disabled members.
This paradigm has already formed in Oregon, the only state to legalize assisted suicide, where it is made available by virtually all of the state’s non–Catholic HMOs, one of which limits hospice coverage to a miserly $1,000. Similarly, assisted suicide is covered as "comfort care" under Oregon’s Medicaid health care rationing scheme, while at the same time, the plan excludes from coverage treatment for life–threatening conditions such as some late–stage cancers and care for low birth–weight babies. That is why many advocates for the poor nationwide, such as the Coalition of Concerned Medical Professionals and organizations that stand up for farm laborers and service workers, now label assisted suicide "death squad medicine" and have begun grassroots organizing against it.
The once strong popular tide favoring assisted suicide may be turning, as witnessed by Michigan’s overwhelming rejection of a legalization initiative last November by 71–29 percent. The American people are slowly awakening to the powerful financial gravitational force that would be created if assisted suicide were legalized, which is why it was so disheartening to see the media (including Richard John Neuhaus in the February Public Square) readily accept a study in the July 16, 1998 New England Journal of Medicine that substantially underestimates the financial impact of legalizing assisted suicide.
The Journal study was conducted by a noted assisted suicide opponent, Ezekiel J. Emanuel, M.D., and a noted proponent, Margaret P. Battin, Ph.D. Yet the study is deeply flawed from the beginning. The authors use statistics published by a pro–euthanasia Dutch physician to predict the number of physician–assisted suicides in the United States under universal legalization. The Dutch study claimed that approximately 2.7 percent of the annual 130,000 Dutch deaths are caused by euthanasia or assisted suicide, including about 1,000 people killed by doctors without request or consent. Applying this 2.7 percent figure to United States demographics, the authors estimate that 62,000 Americans would die each year by assisted suicide were it legal throughout the country.
As bad as that is, the 2.7 percent statistic undercounts significantly the number of people in the Netherlands who actually die at their doctors’ hands. The Dutch, having been intensely criticized internationally over their euthanasia policies, deliberately underplay the extent to which killing permeates their health care system. One technique they use to undercount euthanasia deaths is to apply an overly restrictive definition of "euthanasia." If a doctor kills a patient with a lethal injection of curare upon request of the patient, it is considered euthanasia. However, if a doctor kills the same patient through a massive overdose of morphine administered with the primary intent that the drug kill the patient rather than control pain, that death is not considered euthanasia. This results in a dramatic undercount of the number of people doctors actually kill in the Netherlands, since far more people die through the intentional overdose method than through lethal injections.
In 1991, the Dutch government published "The Remmelink Report," which disclosed that approximately 8,100 people were killed by physicians in 1990 through massive overdoses of morphine. The Remmelink Report did not include these deaths in its widely reported conclusion that about 3 percent of Dutch deaths were caused by euthanasia or assisted suicide. Include the morphine overdose deaths listed in the Remmelink Report’s statistical tables and the percentage jumps to 8.5 percent of 1990 Dutch deaths, nearly triple the figure adopted in the Emanuel/Battin study. Even that horrifying figure is probably too conservative. A British Medical Journal study published in February found that 59 percent of Dutch assisted suicides and euthanasia killings go unreported. Thus, when Emanuel and Battin predicated their estimate of the number of Americans who would die by assisted suicide on the Dutch statistic of 2.7 percent, they utterly destroyed their study’s predictive reliability.
Secondly, the authors predicate their findings on the unrealistic assumption that the people who would "choose" assisted suicide would be those with four weeks or less left to live. Using this time frame, the authors claim that the annual savings from assisted suicide would be approximately $627 million (based on the statistical undercount as related above) using average Medicare costs for end–of–life care. But this assumption is highly questionable. In the Netherlands, there are many documented cases of assisted suicides and euthanasia for nonterminal conditions, including depression over the death of children, fear of giving in to anorexia, haunted memories of the Holocaust, infants born with birth defects, anguish over skin cancer scars, and asymptomatic HIV infection.
Even a cursory review of the assisted suicides that have been made public in this country reveals that most assisted suicide victims were not within a few weeks of the end of their natural lives. Indeed, 80 percent of Jack Kevorkian’s kills weren’t even terminally ill, and at least four had no underlying organic disease that could be determined upon autopsy. It is also important to note that coauthor Battin has said elsewhere she believes that legalized assisted suicide could eventually have a wide rather than narrow application, even to nonterminally ill elderly people who want to die so as to avoid burdening their families with the cost of their care. Moreover, she has recently written that "rational suicide" should be permitted, even if as a "self–sacrifice based on altruistic reasons" rather than on avoiding suffering in terminal illness. Thus, to assert that assisted suicide would be narrowly applied is unrealistic. Indeed, the authors admit that if 7 percent of U.S. deaths were caused by assisted suicide—using a still unduly conservative two months to live assumption—the annual estimated cost savings enters the billions.
The authors make another fundamental error by assuming that the level of physician killing in the United States would be roughly equivalent, or perhaps even lower, than that in the Netherlands. That is extremely unlikely considering the crucial differences between the medical systems of the Netherlands and the United States. While there is an indirect financial incentive in favor of euthanasia in the Netherlands as a method of health care cost control, Dutch doctors are essentially employees of the government and so have little direct financial incentive to kill.
The same would not be true in the United States where managed care compensation contracts may base up to 25 or 30 percent of a physician’s income directly upon his or her ability to contain costs. Such compensation plans place physicians in a direct financial conflict of interest with their most ill and disabled patients, whose cost of care in some cases comes directly out of the physician’s own pocketbook. Then there is the problem of forty–three million uninsured Americans who often delay medical treatment until they are very sick and then generally receive care from understaffed and overcrowded hospital emergency rooms, where they are often seen not so much as patients but as annoyances. It is thus very likely that assisted suicide deaths would actually constitute a higher percentage of total deaths here than they do in the Netherlands.
A final crucial omission from the Emanuel/Battin study further limits its value: the potential role that personal and family financial issues would play in assisted suicide decision making. The authors do not discuss the issue, they claim, because there are insufficient published studies with which to "quantify these savings." Yet it is here at the level of the individual that money could play the most crucial role of all in the "choice" for assisted suicide.
Extended illness or disability can devastate family finances. In a society that increasingly discounts the inherent moral worth of the lives of sick and disabled people, failure to "choose" assisted suicide could be perceived as selfish and insensitive to other family financial obligations. ("Gee Grandma, because we have to care for you, Timmy can’t go to college.") This, in turn, could lead to overwhelming social pressures favoring hastened death—the so–called duty to die already under active discussion in bioethics literature—not to mention the risk of coercion by relatives hungry for inheritance.
Indeed, the Ninth Circuit Court of Appeals, in its 1994 ruling declaring a constitutional right to assisted suicide (which the Supreme Court later overturned), stated that it would be proper for dying and disabled people to take "the economic welfare of their families and loved ones" into consideration when deciding to be killed. Derek Humphry, cofounder of the Hemlock Society, has written recently that avoiding family burdens would be a splendid reason to commit assisted suicide. When the wolf howls, the wise lock their doors.
By adopting faulty statistics, using unduly conservative time–left–to–live estimates, ignoring the pertinent differences between Dutch and American medical practices, and refusing to grapple with financial incentives in assisted suicide decision making at the individual and family level, the Emanuel/Battin study is, in the end, of little empirical value. However, because it carries the imprimatur of the New England Journal of Medicine, it has the potential to do great mischief as a basis for complacency about money as one of the driving forces behind the assisted suicide bandwagon.
Wesley J. Smith is an attorney for the International Anti–Euthanasia Task Force and the author of Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder. His next book, Culture of Death: The Destruction of Medical Ethics in America, will be published next year.