As medical science has developed increasingly sophisticated treatments and medications, it also has given Americans choices about life and death unheard of before. Today, technology allows people to live prolong periods, even after their bodies and minds can no longer sustain bodily functions. The moral and ethical issue regarding euthanasia plays a tug-of-war in our health care system. While many health care providers believe that euthanasia is the most legitimate and cost-effective way to terminate a life, there are those individuals on the other side of the fence who believe that alternative methods to end-of-life care may be a more morally acceptable choice. If legislation supports voluntary passive euthanasia, will this reduce the cost of health care?
Definition of Euthanasia
Euthanasia is defined as the act or practice of killing or permitting the death of hopelessly sick or injured individuals (as persons or domestic animals) in a relatively painless way for reasons of mercy. Euthanasia is also defined as “mercy killing”. There are two forms of euthanasia: voluntary and involuntary active euthanasia. Involuntary active euthanasia refers to ending a patient’s life without their informed consent; whereas voluntary active euthanasia involves a request by a competent patient to another person to administer medication, usually via lethal injection, to cause death. Another term that is synonymous to euthanasia is physician-assisted-suicide, or active euthanasia. Assisted suicide refers to ending a person’s life, with an assistance of a physician. Physician-assisted suicide refers to a physician prescribing medication or other types of interventions to hasten a patient’s death (Jasper 39). There are obvious differences between the act of euthanasia and suicide. Both acts seek to end a person’s suffering; however, in most cases of euthanasia, one only wants to end the physical pain for which there is no other treatment. Euthanasia generally reflects an acceptance or willingness to face the inevitable. To the terminally ill patient, death is the last hope of maintaining any remnants of dignity in a life where there is no longer any control. Euthanasia appears to be the only escape from a life where pain rules this person’s existence.
On both sides of the issue, one must keep the ethical principles in mind. These principles endorse the right of the individual to make health care decisions based on personal values and quality of life considerations, and the responsibility of clinicians to provide humane and compassionate care that is consistent with professional and societal norms. These principles guide end-of-life decision making.
The Principle of Autonomy
This principle asserts that competent individuals have the right to make their own decisions regarding their healthcare, such as refusing medical treatments, whether that choice results in the individual’s life or death. Autonomy should not be restricted by the limitations through other’s values and standards (Kleepsies 29). In the realm of healthcare, healthcare professionals may act paternalistically and ignore a competent patient’s choice. In the U.S. health care system, autonomy is viewed as a patient’s right, if he or she wishes to exercise it.
Informed consent is an ongoing process which helps the patient understand what he or she needs to know in order to make a treatment decision and the health care professional understand the patient’s needs and concerns which might influence such a decision. Ideally, the patient makes a voluntary, informed decision regarding care.
It requires information presented at a level that the patient can understand, in an environment that supports good decision making. It also requires active support of and respect for the patient’s right to make that decision. Informed consent promotes and protects patient autonomy.
The Principle of Beneficence
Beneficence is the action to do well; a moral obligation to act for the benefit of others (Kleepsies 30). When a treatment provider enters into contract to provide services to a patient, a commitment and obligation meets the health care needs of the patient, and to promote their well-being (Kleepsies 30). Fidelity is defined as loyalty and/or promise-keeping. In some cases this term is used to describe a duty to be loyal. In other instances it is used to refer to the duty to keep one’s promises. With managed care contracts and the increase in institutional affiliations, more health care professionals are finding themselves in situations where they have to choose between honoring a contractual obligation or doing what they believe is in the patient’s best interests. They may also find that their obligations to different third parties conflict.
The Principle of Mercy and Nonmaleficence
Primum non nocere or above all do no harm. This directive stems from the Hippocratic Oath. Nonmalificence warns the health care provider to abstain from procedures that may inflict suffering or pain (Kleepsies 32). This principle is also seen as a component of the principle of mercy as it warns us not to inflict harm or suffering needlessly.
Where possible, one ought to relieve the pain or suffering of another person, when it does not contravene that person’s wishes, where one can do so without undue costs to oneself, where one will not violate other moral obligations, where the pain or suffering itself is not necessary for the sufferer’s attainment of some overriding good, and where the pain or suffering can be relieved without precluding the sufferer’s attainment of some overriding good (Kleepsies, 2004, p. 31).
The Principle of Justice
This principle refers to “fair, equitable, and appropriate treatment in light of what is due or owed to persons” (Kleepsies, 2004, p.32). In the realm of end-of-life care (and health care in general), distributive justice plays a key role. This refers to the fair distribution of services and resources (Kleepsies 2004). With scarcity of services and resources increased competition exists for them. Life-threatening illnesses put these resources to the test, and decisions about who is treated versus who is not treated, quickly becomes a question of who will live and who will not live (Kleepsies 2004).
These ethical principles play a key role in the iron triangle of cost, access, quality of healthcare and how the health care system will aid the Baby Booming population, who are heading down the steep hill of chronic illness, questioning their mortality. The debate is about the limits of individual freedoms and the political power of the Baby Boomers, now at the age when they are beginning to contemplate their mortality. It’s about an ageing population and a limited health dollar. It’s about an increasingly educated population losing its awe of the medical profession (Magnusson, 2002, p. 36).
“Death with dignity” has become a catch phrase used by euthanasia activists, who believe euthanasia respects a terminally ill patient’s dignity, and meets ethical principles of autonomy and beneficence.
The correlation between increasing support for legalization of euthanasia and a growing fear of becoming trapped in unacceptable position of dependency brought by medicine’s ability to prolong dying (Manning 27). Terminally ill patients request euthanasia for a variety of reasons. Out of the five most common reasons, 80% of those reasons fell under “psychosocial factors” (Rosenfeld 2004). Fifty-seven percent of patients cited “loss of dignity” as their prime reason. Other reasons included “unworthy dying” by 46% of the patients. Thirty-three percent of the patients claimed being dependent on others and 23% said tiredness of life. Forty-six percent of the patients cited the only physical symptom on top of their list was pain (Rosenfeld 2004). Depression was listed as a factor in 55% of these cases. Patients would commonly request that physicians prescribe them anti-depressant or anti-anxiety medication (65% of these cases). Only 19% of those patients who suffered from depression requested assisted suicide but 39% of those cases, lethal injection was sought (Rosenfeld 2004)
Assisted Suicide in Oregon
In November 1994, the state of Oregon voted in favor of the Death with Dignity Act, also known as Measure 16, which legalized physician-assisted suicide but did not authorize active euthanasia (Magnusson 2002). The law came into effect on October 27, 1997. In November 1997, sixty-percent of Oregon voters passed legislation verifying their support for this act a second time. In October 1999, the United States House of Representatives passed the Pain Relief Promotion Bill, which made it an offense for doctors to prescribe barbiturates, specifically for purposes of assisted-suicide (Magnusson 64).
The Oregon Dying with Dignity Act or ODDA allows any adult with specific-met conditions to be prescribed medication to terminate his or her life. These conditions include: (a) over 18 years old, (b) an Oregon resident, (c) diagnosed with a terminal illness with a life expectancy of less than 6 months, and (d) capable of making a sound decision (Rosenfeld 148). Assuming that the patient meets these conditions, he or she must make two verbal requests to his or her physician 15 days apart as well as provide the physician with a written request no less than 48 hours before the prescription is provided and must be witnessed by a non-relative (Rosenfeld 148). A disturbing fact is that patients that utilized ODDA were young, Caucasian, well-educated people with a diagnosis with cancer or ALS (Rosenfeld 156). Loss of autonomy leads the main reason for lethal injection request, followed by poor quality of life, loss of dignity, and pain or fear of pain (Rosenfeld 2004)
The right to control the course of one’s medical treatment has become increasingly accepted as a general ethical principle in health care. Whether the desire to determine the course of one’s illness and treatment reflects a psychological need for control or an American focused on value we place on privacy and autonomy or some combination of these and other factors, patient autonomy has consistently grown over the last century. This movement gave birth to the Patient Self-Determination Act of 1990. This legislation requires Medicare-reimbursed institutions to inform the patients of their right to participate in medical decisions and advance directives. Some conditions institutions must adhere to are providing information concerning an individual’s statutory right to make decisions concerning medical care. This includes the right to accept or deny treatment and to prepare an advance directive, (b) provide a copy of the institution’s written policies with respect to implementation of such rights, and (c) obtain documentation of patient’s signature of the advanced directive in their medical record (Rosenfeld 44).
In more recent cases, Lord Joel Joffe- a retired human rights lawyer who defended Nelson Mandela, requested the right to assisted suicide enshrined on the statute book (Bid to Legalise Assisted Suicide). Other alternatives to assisted suicide included hospice and palliative care. Here, the patient would have to make a written statement to declare their wish to die. This Patient Assisted Dying Bill consists of safeguards to ensure that the vulnerability of the society is protected.
Health care Cost in Supporting Euthanasia
The principle of common good goes beyond the utilitarian argument for placing limits on self-determination, and calls us to consider the impact that allowing euthanasia might have on our general attitude toward preserving life and the taking of life. Will euthanasia be used as a cost-saving measure to avoid expensive long-term disability care? Or as an easy fix to the complex problems of aging and disability?
Euthanasia or physician-assisted suicide can help reduce the high cost of health care for terminally ill patients and possibly make new financial resources available to serve for the common good. Chronically ill and terminally ill patients contribute the most to the rise of health care. 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 certainly could become a means of cost containment. In the United States, thousands of people have no medical insurance; studies have shown that the poor and minorities generally fall victim to lack of accessibility for available pain control, and managed-care facilities offer 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 individual patient treatment and care and forced patients into treatments causing death.
Death is a foregone decision. Euthanasia is a topic that provokes as much controversy as capital punishment, primarily because it is irreversible. For most people in Western society, death is an issue that most prefer be hidden behind the closed doors of a hospital. This fear is best left unspoken and many find it uncomfortable and disturbing. This fear of a ‘thing’ that nobody has any control over is very much apart of our society. In the health care realm, a health care professional’s primary concern is the preservation of medical resources and cost containment, as opposed to the betterment of human life.
Cost of Euthanasia
Financial pressures may also lead to incentives for active killing by limiting funding for terminal care (Wekesser 1995). Legislators consider the cost of terminal care with Medicare and Medicaid along with private insurers may take it as an obligation to encourage more cost effective ways of dying. Cost pressures will force future adoption of practice protocols based on a patient’s condition, likely outcome and cost of alternative treatments. If euthanasia is added to this economic pressure, the freedom to choose well set the stage for unsubtle financial coercions that will determine how many of us die, especially the indigent, uninsured, and underinsured populations (Wekesser 1995).
Hospice and Palliative Care
Until the early 1990’s, ‘palliative care’ was described as taking care of dying patients, especially dying cancer patients. Demographic and technological changes such as the aging population, along with advances in pharmacological and surgical techniques have shaped the historical view of palliative care (Meghani 2004). World Health Organization (WHO) defines palliative care as
an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual
(Meghani 2004, p.155).
The concept of palliative care in the U.S. has evolved to address the needs of a wide range of patient population to alleviate suffering and improve their quality of life. The four attributes of palliative care are total, active and individualized patient care; support for the family; interdisciplinary team approach; and effective communication (Meghani 2004, p. 157). The hospice approach to the treatment of terminally ill focuses on relieving the physical symptoms of patients provides psychological and social support for both patient and family.
The National Hospice Organization defines hospice as:
Hospice affirms life. Hospice exists to provide support and care for persons in the last phases of incurable disease so that they might live as fully and comfortably as possible. Hospice recognizes dying as normal process whether or not resulting from disease. Hospice neither hastens nor postpones death. Hospice exists in the hope and belief that, through appropriate care and the promotion of the caring community sensitive to their needs, patients and families may be free to attain a degree of mental and spiritual preparation for death that is satisfactory to them
(Wekesser 1995 p.119).
Legalized killing would create a new ethical reality by sanctioning these killings through removal of ventilators and feeding tubes (Wekesser 1995). Part of the opposition to pro-euthanasia is the assertion that palliative care, or comfort care, can adequately relieve pain and distress, thereby avoiding the escape route for euthanasia. Palliative care specialists are keen on drawing attention to the success of their specialty in providing comfort care and regard support for euthanasia as a sign of lack of information and ignorance by doctors and patients (Magnusson 2002). Some see the push for euthanasia primary as a symptom of the failures of doctors to communicate to their patients, failure to respect a patient’s choice by discontinuing treatment when it is futile, and their failure to practice good palliative care (Magnusson 2002).
Health care Cost
While U.S. heads the list of top countries regarding per capita health care expenditure, recent reports indicate that the existing health care structure is in much needed care of patients diagnosed with potential or actual chronic illnesses (Meghani 2004). Medicare is the prime insurance provider of hospice care in the United States for people age 65 and over. Unlike many developed countries that operate under a centrally administered health system such as United Kingdom, and Canada, the health care system in the United States mainly operates based on market-forces. Therefore, cost-containment has remained central to most public policies. The effect of this market place system is evident among Medicare beneficiaries, where hospice enrollment varies by the insurance type (Meghani 2004).
Presently, aside from hospice care, no other third-party reimbursement is available to support non-traditional palliative care. The lack of adequate reimbursement has resulted in an improvised partnership and research projects such as independent hospice entity into a contractual relationship with hospital(s) or integration of a hospice program within a hospital or health care system. This is a prime example of vertical integration (Meghani 2004).
It is important to bear in mind that the key element of the debate of legalizing euthanasia is to reduce the cost of health care. One danger of this is that euthanasia would be seen as a “convenient” solution to the heavy demands on care made by certain types of patients. The kind of humane impulses which have sustained the development of hospice medicine and care would be undermined because too many would think euthanasia is a cheaper and less personable demanding solution. With managed care, the quality of care is paramount. But that quality of care is compromised when cutting cost is a factor. Therefore, those patients requiring quality care are overshadowed by reduction of care (Smith 1997).
As providers of managed death, many physicians will be sincerely motivated by respect for patient autonomy, but the cost factor will always lurk silently in the background. This will be especially true if they are providing managed death in a setting of managed care. A perilous line of argument might then emerge:…1) Too much money is spent on health care; 2) certain patients are expensive to take care of (i.e., those with physical disabilities and the elderly); 3) these patients appear to suffer a great deal, lead lives of diminished dignity and are a burden to others;…4) recognizing the diminished dignity and suffering and burdens borne by these persons and those around them, their right to euthanasia or assisted suicide should be legally recognized; and 5) the happy side effect will be health care cost savings (Smith 1997, p.154).
The Patient Assisted Dying Bill may not be helpful if a patient is in a vegetative state and cannot express his or her wishes due to their condition. A prime example of this is the ongoing 10-year saga of the Terri Schiavo case. The controversy lies in which to let Terry die, a decision rendered by her husband Michael, or to keep her alive and offer some sort of intense therapy to improve her health, a decision rendered by Terry’s parents. President Bush allowed the federal courts to review state court decisions in the case (Franken 2005).
After thoroughly researching both sides to this sensitive issue, I believe that legalization of voluntary euthanasia will reduce the cost of health care but at a cost of a patient’s life. If a patient makes a decision to terminate its own life an advanced directive must be prepared. The advanced directive will provide more autonomy to individuals in order to ensure the fulfillment their medical wishes. This directive will also foster fidelity between the doctor and the patient. One powerful drive is the demand for people to make their own decisions. This call for autonomy says that, while a doctor may have a better understanding of the patient’s medical needs and the likelihood of success of any particular treatment, individuals have primary responsibility for their health and must live with the consequences of any decisions. The previous paternalistic mentality of ‘the doctor knows best’, has been replaced with the notion of ‘informed consent’ – the idea that clinicians give information so that patients can make sound choices.
In the example of the Terry Schiavo case, this 10-year battle would not have been dragged if not for an advanced directive by Terry Schiavo herself, expressing her last wishes. The $1 million medical malpractice award that Michael Schiavo won in his wife’s case quickly diminished due to the vast medical expenditures to keep her alive (CNN 2005). Legalizing voluntary euthanasia compromises the ethical principle of benevolence, justice and nonmalificence.
Legalization of voluntary euthanasia will reduce the quality of care by physicians to patients who lack insurance, or are impoverished. The surplus of chronic diseases in this country belongs to the underserved, underinsured, and uninsured population. As their quality of life diminishes, patients will opt for voluntary euthanasia which will start a vicious cycle to the reduction of cost of health care.
Legalization of voluntary euthanasia would create a profound change in medicine, a change that could bring many other unforeseen changes and social consequences for the profession and the public it serves. Persons can be best served by adopting measures that make the process of dying more respectable, humane, and dignified by for all (Wekesser 1995). In essence, this means adopting a hospice inspired strategy of accepting death when it is inevitable, by providing support to ease suffering and using every method to control pain. It is a doctor’s prerogative to inform patients of the alternative of palliative care and/or hospice care. Improved hospice services can improve the quality of care and reduce its cost. Educating patients and health care providers on hospice care will render the issue of euthanasia essentially moot (Wekesser 1995).
In the end, legalizing voluntary euthanasia can cause a conflict of interest between physicians and patients. Hospitals may be predisposed to encourage physicians to gain consent of some patients as cost-control measures. Patients should be cognizant of alternatives to voluntary euthanasia such as hospice and palliative care. These alternatives will aid in cost-saving measures along with provide quality care to patients in their end-of-life care. Patients should also be cognizant of obtaining an advanced directive to avoid hasty decisions in one’s death. Every life is a worthy life; cost of legalizing euthanasia should not play a factor in the termination of life.