Saturday, September 13, 2008

Insurance-Promoted Suicide?

At Covert Rationing, "Dr. Rich" bemoans physician-assisted suicide and euthanasia. He presents a letter sent by an insurance provider, which advertises to its subscribers that such interventions would be, what Dr. Rich terms, "compassionately offered and cheerfully paid for." Dr. Rich questions the motivations of such promotions as follows:

"When reducing costs and preserving individual autonomy work in the same direction (as they do with advance directives and assisted suicide), it is easy for them to claim that they are motivated by their passion for individual autonomy. But when reducing cost and individual autonomy are at odds (as with medical futility), they immediately side with reducing cost, and not with autonomy."

Dr. Rich is correct that decisions concerning euthanasia are not necessarily driven by pure motivations, a concept especially apparent when "patient choice" is championed inconsistently. However, it does not follow that nobody would recommend physician-assisted suicide or euthanasia if it didn't save a bureaucrat some money (as Dr. Rich seems to suggest), or that it is inherently unethical.

Let's assume that sometimes euthanasia is appropriate, which we'll define as meaning that it is the intervention that the patient would have really, truly wanted, had we been able to glean his choice, unsullied by the pressures of other stake-holders. If the insurance company advocates for euthanasia, its recommendation could be categorized as follows:

1) Inappropriate, but saves company some money (Company as devil)
2) Inappropriate, and the company loses money (Company as accidental devil)
3) Appropriate, and company loses money (the company as merciful angel of death)
4) Appropriate, but also happens to save company some money (company as possible applicant to become devil, but assigned as merciful angel of death.

In option 4, unlike option 2, the company's interests happen to coincide with the best interests of the patient. Therefore, just as we shouldn't automatically accept a company's recommendation when it has something to gain, we shouldn't automatically reject their recommendation, just because it has something to gain. We need to simply work harder to establish and implement the patient's will.

Ideally, the power of the insurance company's biases would diminish if its contracts delineated, at time of patient enrollment, the extent of coverage provided for life support, at various degrees of brain damage. If it were plainly written, "we do not provide continuing treatment for patients in a persistent vegetative state, when such a diagnosis is determined by three separate physicians," then conscientious objectors would choose to take their money elsewhere. They could also pay a higher premium for the expectation that their organs would be kept alive. It would then be up to the hospital and patient's family, when the time comes, whether or not to keep the patient on life support, and who must pay for it. The insurance company ideally decides what medical procedures it covers, not whether such procedures are medically justified.

To me, such issues underscore the potential dangers of implementing universal health care. We could potentially be left with a system, in which everyone foots the bill for ventilators that most would have refused for themselves. Alternatively, we could inappropriately end up pulling the plug on people, as administrators ration away all costly end-of-life care medical in favor of services perceived as more urgent. Inevitably, we'd draw the line at a place that runs counter to the wishes of most patients, who have complex values and needs.

This is not just an economic issue, but a potentially significant instigator of the Culture Wars. As much as social conservatives hate taxes and abortion, what aggravates them most is that their taxes are complicit in providing abortions. Most people have an easier time minding their own business when they aren't footing the bill for other people's perceived unsavory activities. Once the government starts making decisions about the extent of coverage for euthanasia, transgender surgery, abortion, and alternative medicine, every one will find his own beef. Hence, economic issues will increase every one's aggravation concerning social issues.

What about people who can't afford health care? Should they be the ones whose plugs are automatically pulled, because they lack the resources to choose the more expensive option? Ideally, people who care about such people's wishes, concerning this issues, would help fund the life-saving measures of such terminally ill patients. It is a difficult matter that the patients wouldn't get to choose their fates, and yet also a difficult matter that an unwilling sponsor can't choose the fate of his taxes, which may have otherwise gone to someone else's cancer treatment. Yet, one way to solve this problem would be to implement government health care policies in which patients are simply given cash to purchase insurance and treatments. After ranking their own list of medical priorities, patients would choose among private plans. They may choose to buy a plan with comprehensive ventilator coverage, or a plan that comes with extra chiropractic visits.

Admittedly, taxpayers would still indirectly pay for people's health care decisions. But the contrast is analagous to the theoretical (and likely rare) person who spends his welfare dollars on prostitution and drugs, rather than the a person who obtains such goods and services from a benevolent single payer, who compensates pimps and dealers directly. In the latter, the government, on behalf of the taxpayers and society overall, chooses to pay for objectionable services. In the former, we simply gave the person some cash, to spend under his own discretion and autonomy. The choices he makes are ultimately his own.(As an aside- for those who believe that I am calling doctors pimps, please note that I am making an analogy, rather than a comparison. Although doctors as drug-dealers is not as off-base).

When it comes to euthanasia, and all other controversial medical issues, the more we allow people to make their own decisions, the less we have to worry about competing profit motives and our personal moral conundrums.


Rhea said...

Interesting to know.

Heal Spieler said...

Thanks Rhea. I'm glad you're reading my blog.