Bioethics: Economic Motives for Physician-Assisted Suicide

July 31, 2010

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Economic Motives for Physician-Assisted Suicide

Maxwell J. Mehlman, J.D.

The debate about physician-assisted suicide is replete with concern over the role of economic factors. Justice Rehnquist, writing for a majority of the Supreme Court in Washington v. Glucksberg, noted the state's interest in protecting patients from "the real risk of subtle coercion and undue influence in end-of-life situations," particularly those patients "whose autonomy and well-being are already compromised by poverty." Rehnquist went on to object that, "[i]f physician-assisted suicide were permitted, many might resort to it to spare their families the substantial financial burden of end-of-life health-care costs." Justice Souter, in his concurrence, pointed out that "[p]hysicians, and their hospitals, have their own financial incentives, too, in this new age of managed care."

These concerns are shared by many scholars. The New York State Task Force on Life and the Law warns that "patients may be pressured to consent to euthanasia when their care is expensive or burdensome to others." Susan Wolf urges us to "consider the dangers of assisted suicide in the context of managed care." Nancy Osgood laments ageism in America which may lead older people to seek assisted suicide rather than become "an economic burden on younger members." John Kilner observes that, "if choosing death becomes a socially accepted alternative, then patients needing much care may begin to consider themselves selfish merely for choosing to live." "The very autonomy sought to be exercised [by permitting physician-assisted suicide] cannot be invoked if it is only allowed to be considered in a medical environment where the primary source of assisted suicide advice comes from physicians with economic interests that could objectively be at odds with those of the patient," states one student law review note entitled "Undue Economic Influence on Physician-Assisted Suicide." Another note objecting to physician-assisted suicide declares simply that, "[a]mong the many factors that influence America's health care decisions, money is the most invidious."

The economic objections to physician-assisted suicide fall into three categories:

First, it 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.

Physicians also may feel that they must represent the interests of society in encouraging patients to choose less costly alternatives. Physicians may see themselves as instruments of "bedside" health care rationing. They may favor assisted suicide, particularly for older patients, in line with the beliefs of those like Daniel Callahan who think that the elderly have enjoyed enough of the resources of society and should make way for the young.

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