Section 7 - Rationing  and Death - Covert rationing and end-of-life care

Is it merely a coincidence that the first state to approve a program of explicit health care rationing is also the first state to approve physician-assisted suicide?  

Perhaps this is not a fair question, especially if you’re an Oregonian.  Oregon is the only state whose citizens have had the courage to openly address the issue of health care rationing, (their efforts in this regard are discussed in detail in the Section 8), and perhaps it is not surprising that such a people would also have the nerve to take up a second highly contentious issue related to health care.  So we concede the possibility that Oregon’s passage of laws related to both of these issues may indeed be a coincidence of courage.

At the same time, coincidence or not, one must admit that it is at least interesting to find the first operational assisted suicide law so plainly juxtaposed against the first openly acknowledged system of rationing health care. I believe that this juxtaposition neatly illustrates the relationship between the increasingly urgent “end-of-life” movement and the need to limit spending.

There are actually three areas of hot contention related to “end-of-life” medical care (the care of patients at or near the time of their death) – these issues are advance directives, physician-assisted suicide, and the delivery of futile care.  All three areas of controversy involve legitimate ethical dilemmas, about which respected ethicists have argued and continue to argue on either side.  In each case the ethical point of contention is the same – that of individual autonomy.  In essence, all three ask this question – how much control will a patient have over the events that surround his or her own death?

The end-of-life controversies - Autonomy, or cost?

As we have seen, the autonomy of the individual – a person’s right of self-determination – is the cornerstone of the American belief system.  Yet, individual autonomy is not perfect even in concept; it has inherent limitations.  For instance, in the pursuit of life, liberty and happiness, no person has the right to limit or jeopardize the rights or welfare of other individuals (i.e., of society.)  This limitation creates an unavoidable tension between the rights of an individual and the rights of society.  Indeed, the general problem of how to protect individual autonomy without sacrificing the legitimate needs of society accounts for many of the domestic conflicts that have taken place during our nation’s history. 

Not surprisingly, the issue of autonomy is central to the end-of-life disputes. Returning the authority to make end-of-life decisions to the dying patient can restore a measure of control, and add a final measure of dignity to his or her life.  To the “end-of-life” movement, the battle is for affirmation of the individual autonomy of the dying patient, and against a technocratic health care machine that seems geared toward extending life by all possible means.

But also central to these disputes, though much less openly discussed, is the issue of cost.  In virtually every plea for the expansion of end-of-life autonomy is an aside (often in parentheses) as to how much money is being spent today caring for patients in the last few months of life.  Up to 35% of Medicare expenditures in any given year, they might say, will go to the 6% of enrollees that die within that year.  The clear implication is that, by honoring individual autonomy, as an extra bonus we also stand to save countless millions of dollars.  It is therefore not surprising that those who cut the checks, health insurers and the government, have generally expressed sympathy and support for the end-of-life movement.

Next: Advance directives

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