Managed Care, Autonomy, and Decision-Making at The End-of-Life

Abstract

Some argue that legalizing physician-assisted suicide poses intolerable risks, especially as we move from a system of fee-for-service health care to managed care. Although we need to be concerned about physician-assisted suicide in the context of managed care, physician-assisted suicide poses risks in a fee-for-service system too. In addition, we need to be concerned about the risks posed not only by physician-assisted suicide but also by the well-accepted practice of forgoing life-sustaining treatment. Instead of focusing on the manner of hastening death or the type of health care system, we need to show more concern for protections to assure that no matter how terminally ill patients seek to hasten their deaths, if they do, and regardless of the type of health care system, that their decisions are genuine reflections of their own wishes. Of course, we need to design safeguards that are sensitive to the nature of the health care system and the particular kinds of problems that it might pose (such as managed care incentives), and we need to take into account any special problems posed by physician-assisted suicide in contrast to termination of life support, if there are any. There is only the weakest evidence, however, that we need to prevent the legalization of physician-assisted suicide simply because of the ascendance of managed care.

Keywords: physician-assisted suicide, legalization, actively hastening death, passively hastening death, palliative care, pain control