To me this still reads a bit like an American moral panic. The 27-year-old woman, for example, wasn't granted MAID for being autistic. The ruling was that her autism did not prevent her from making the choice for herself. Her actual conditions, if any, were undisclosed. Similarly, the woman with cancer is facing problems with a badly managed health system, not with MAID. My father is in a very similar situation, and was given treatment immediately and is very happy with the results, those wait times are not normal.
A lot of this seems to come down to whether you view this as a matter of individual freedom. To me what matters is the capacity to make the choice – and depression may be disqualifying then! But I don't understand why I should be forced to live a life of suffering, however I perceive it, just because some other people have terrible arguments about euthanasia being good for the country. You seem to believe that suicide is ALWAYS the wrong choice, except it truly terminal/painful cases, which is a widespread belief but to me, it's a choice you're making for me. When theories came out that abortion causes crime reduction, did you think to ban abortion because that's a perverse incentive?
The concerns I do share are a) using it as an excuse not to fix the health care system at all, which in Canada is facing problems and b) not screening/counseling for capacity to consent.
It's worth quickly flagging that it's not just governments and governmental health care systems that have these incentives. American private insurers would have exactly the same incentives for their most expensive patients to die and stop costing them money. Before the ACA, they would try to kick them off their books and then deny them insurance on the grounds of a pre-existing condition, but since they can't do that any more, trying to get them to die in a way that they can't be sued for malpractice would suit them very nicely thank you very much.
This brings up a problem with American health care in general. The standard 15-minute appointment does not allow for the true exploration of alternative treatments. My experience is that I am offered alternatives less than 20% of the time. Generally speaking, the doctor simply makes a recommendation.
My ordinary practice is to accept the recommendation and when/if it fails, to go on to the Internet to get a broader picture of the options that exist. Of course, I'm internet savvy enough to recognize responsible sources of medical information and read scientific papers.
I sympathize with the argument here but I'm not sure Noah's proposed remedies are completely on point.
In countries like Canada and the UK where health care costs are socialized, there has to be some sort of collective decision about which treatments justify themselves on an expected cost/benefit basis. The availability of MAID shouldn't affect that calculus, but it does have to be performed.
So it's not clear that the Canadian cancer patient's doctors made the wrong decision. It sounds to me as if their rationale was "This chemotherapy is very expensive and it will only lengthen your life by a few months at most, so we won't pay for it... and by the way, you should consider MAID". That's very different from saying "we refuse to treat you •because• you can painlessly kill yourself, so do that".
I have treated many people with clinical depression and find your article very worthwhile as an account of the real problems in their or their agents making any decisions which require capacity. Fwiw, I should state my position on assisted dying - I am in favour of it in extremis though not outwith a legal and ethical framework (easier to say than conceptualise).
You use the terms interchangeably, but medical aid in dying and euthanasia are slightly different things. In medical aid in dying, the party who wishes to die must decide independently to go through the process and self-administer the medication cocktail which will cause them to die, whereas in euthanasia, someone else can in cases make the decision and someone else can give the medication to the person (who may in cases be comatose or otherwise unable to self-administer). In the US, only medical aid in dying is legal.
Doctors are not the only ones who face mixed incentives on the issue of assisted suicide. Some close human relationships are blissful, and the thought of death is agony. Other relationships have difficulties, and the thought of release has attractions. Clint Eastwood's film “Million Dollar Baby” was a great contribution on the issue.
I had my own experience with a relationship that was both rewarding but increasingly difficult. Over 20 years ago, I met a man who had become an alcoholic at nine years of age, by finishing up the booze left around the house by his alcoholic mother.
He was a brilliant man with whom one could discuss any topic with pleasure and profit. He was also warm and affectionate. He had a buoyant, childlike enthusiasm and was a total sucker for stuffed animals.
For a while, he cut down on his drinking very significantly. The last two years I knew him, however, he went into a sharp decline. His ability to control his drinking and emotions decreased dramatically. His outburst of rage became sudden and unexpected.
We had enjoyed going on trips together. I invited him to a final trip to Maine, 2,000 miles from my house. I thought to myself, “If he can behave himself, we'll have a great time. If he can't, I will leave him far from my house without guilt because I know he has the smarts to care for himself."
I left Charlie in Maine in August 2006. He died of a heart attack in a homeless shelter in Maine in January 2007. I admit that my first reaction was relief. In his case, it could be said with confidence that he was in a better place, inasmuch as planet Earth clearly lacked the resources to address his pathologies.
Charlie was buried in a rural graveyard near Carthage TX where one quarter of the graves shared his last name. His family warmly thanked me for “What you did for Charlie.” Charlie is buried next to his mother, whom he had nursed through her final months with cancer. In his grave I placed a large stuffed monkey, representing Charlie, hugging a small yellow chick representing his mother. To this day, from my bed I can see my souvenir of Charlie: a tiny enthusiastic stuffed duck with big eyes and boundless irrational exuberance.
Even though I am religiously opposed to suicide, I would have been tempted to agree to suicide if Charlie had suggested it during those last two difficult years. So, it is not only doctors but many, may close friends and relatives who will face tormenting dilemmas and competing motivations.
"First, there’s the possibility that people could simply be denied life-saving treatments if health providers consider MAID a cheaper, acceptable alternative. The moral justification for MAID is based on the idea that people should get to choose when to die with dignity. But some people don’t want to choose death. If a health care system makes that decision for them, refusing to pay for non-MAID care, it has violated the principle that death should be a choice.
For example, here’s a story from last year about a Canadian woman who was given a poor abdominal cancer prognosis and urged to die with MAID instead of getting surgery and chemotherapy. She refused, and went to the U.S. for treatment. Canadian health insurance refused to pay for the treatment:"
But this is how most big government health care programs operated, even before euthanasia considerations. They certainly don't pay for little hope extraordinary measures that are much more common in the US. And in fact one area where European health systems lag in survival is cancer care, because they've been trying to economize on care for years.
In Oregon we have a long standing program of death with dignity. My first husband used it when he had ALS. He was very grateful to have the option. In Oregon, participation is limited to those with a fatal illness. The patient must request it themselves and must meet criteria to show that they are able to make an informed decision. I’ve not heard of any misuse of the program. It is used each year by several hundred people. Studies have shown that people who choose this path like to control their lives.
First an important clarification. Canadian doctors are not allowed to mention or otherwise bring up MAID as an option. Other health care providers possibly but not doctors. The woman with cancer would have been offered palitave care if she was facing cancer without a likely treatment. There is a growing thought that spending the majority of your final days undergoing painful treatments to extend your life only a little. For example would you want to live 13 months instead of 12 if you had to spend half that time in hospitals? They do the best with the information they have.
Depression is often resolvable, not always, and as such there will be a lengthy process before MAID is accepted by the doctors, not just one but two have to sign off.
In Canada doctors are in the top 1% of earners, need to be a bit isolated from the problems of every person they see, generally getting older and might just be out of touch with the person sitting in front of them so they can't always be the fountain of compassion we might all need. From my own experience doctors like to work on thing they can easily fix. 3 years of testicular pain near a dozen doctors (some just filled th eperscription I asked for) and 2 specialists later I was greated by a doctor with "so are you filling out the paperwork for a gun (inturupts) it doesn't matter I couldn't help you anyway." He didn't really think I should go home and buy a gun (not an easy task in Canada) but this was his unsympathetic way of ensuring I didn't come back. 5 more years later and well you learn to live with (and avoid doctors) it but it would have helped if just one of them had offered anyting that might have made it easier to live with sooner. I was quickly screened for cancer and then well you are often on your own.
I 100% share the concerns about euthanasia/MAID, and the extremely difficult interface with mental health.
But the financial incentives here are absolutely not so simple as presented. For doctors and hospitals it is almost entirely backwards, in Canada at least. A large portion of a medical costs accrue in the last months of life. That is income for the doctors and hospital. They are are fee-for-service in large part. Healthcare would not have constant budget issues if doctors were generally incentivised not to treat, rather than the opposite. For the payors, the state and insurers, there is a weak incentive to get euthanasia rates up. But they can't reach down into individual consultations. I say weak incentive because you have to ask whether a state administrative bureaucracy really has an incentive to shrink its own budget?
In the UK (where I have researched healthcare costs at the end of life). There is much less fee for service for doctors, so they do not have a contrary incentive. However, there is still no incentive for them to save the payors money by recommending MAID. And hospitals are still fee for service in an internal market structure so they are incentivised against.
Euthanasia is on the radar, and quite well guarded. However, under the radar is the "letting go" of patients. Deciding to not start a new treatment and so letting the person die. Or more often than not, staying in the zone where no decision is taken, and the person slides away. It is in this zone where incentives can do their perverse magic.
The problem with euthanasia is "if you are in your right mind". When some people age they lose cognitive recognition. We write health directives that specify "do not resuscitate" . I want a mental directive that says when "I can't recognize my spouse and/or kids I want to die"
“If you disagree with that — if you think that all human life is sacred and should be preserved and protected at any cost, or even if you just feel like there’s something wrong with euthanasia that you can’t quite express — then fine. I respect that viewpoint. That’s not the debate I want to have today.” Thank you, truly and sincerely. I am a devout Christian and someone who deeply believes this. I love so much of what you have to say. I spent a career in finance and was initially drawn to your Substack (actually, even prior to you making that transition) by how fresh your economic insights were. While I am likely not as smart as you I am smart enough to know that you are exceedingly sharp. I am also kind of astonished at the amount of information you consume and your output. I used to think this about Paul Krugman until he became, well, a bit rabid. I do not consider myself right or left. That is a distinction that makes arbitrary and unnecessary dissections and rather like making a big deal about whether you drink Seven-Up or Sprite. I have wondered at times whether I would be able to continue to be a part of this little community you’ve created. I know you don’t agree with me on the deepest questions but I’ve wondered whether you would consider me less reasoned for that. I find that to be a somewhat odd posture for many of my elite friends. I am afraid they drank a little too deeply from the well that their professors served them at institutions that were overwhelmingly started by people largely like me, regarding the deep questions (see: “God and Man at Yale” Buckley). My church is literally full of PHD students and professors from UC Berkeley. I know you went to Stanford, that notwithstanding, I think we would have to conclude, objectively, they’re not idiots. We’re not idiots, you’re clearly not an idiot. Let’s shelve that and see if we can get a few more years out of this deeply flawed and terribly beautiful experiment known as America.
I appreciate your candor regarding depression very much. 🙏 I hope it's a battle you always win.
My mother is in the advancing stages of Parkinson's. Ive watched my father in law drown in his own fluid in hospice due to cancer. My fathers, mother in laws, death were sudden and in retrospect, a blessing. 3 siblings as a family have struggled to keep up with my moms care needs. It's been emotionally and physically very difficult. It's not an end you would wish on an enemy. I support assisted suicide. If you've ever been in a care home, or nursed an elderly person, the loss of independence can be a prison to them. Particularly the loss of the mind. I sat in on a discussion with my moms neurologist about what would happen to her body over time. It was devastating and not something I'll ever forget. The weight of care is societal. I'm not even sure how to quantity it.The vast # of care workers and nurses are phenomenally compassionate. As an agnostic, it's God's work and the most human kind of care. I'm not disgusted by Parris' argument. It's cruel but frank.
Stringent metrics, familial input, checklists, client directives are essential. Real compasion.
We already treat each like commodities. A discussion about humans as a natural part of an ecosystem that brings death back into the picture in a world that has tried to avoid the topic, particularly in wealthy countries would ground us all. Particularly younger generations. It can be a profound teaching moment about how we live, love and choose to die.
To me this still reads a bit like an American moral panic. The 27-year-old woman, for example, wasn't granted MAID for being autistic. The ruling was that her autism did not prevent her from making the choice for herself. Her actual conditions, if any, were undisclosed. Similarly, the woman with cancer is facing problems with a badly managed health system, not with MAID. My father is in a very similar situation, and was given treatment immediately and is very happy with the results, those wait times are not normal.
A lot of this seems to come down to whether you view this as a matter of individual freedom. To me what matters is the capacity to make the choice – and depression may be disqualifying then! But I don't understand why I should be forced to live a life of suffering, however I perceive it, just because some other people have terrible arguments about euthanasia being good for the country. You seem to believe that suicide is ALWAYS the wrong choice, except it truly terminal/painful cases, which is a widespread belief but to me, it's a choice you're making for me. When theories came out that abortion causes crime reduction, did you think to ban abortion because that's a perverse incentive?
The concerns I do share are a) using it as an excuse not to fix the health care system at all, which in Canada is facing problems and b) not screening/counseling for capacity to consent.
It's worth quickly flagging that it's not just governments and governmental health care systems that have these incentives. American private insurers would have exactly the same incentives for their most expensive patients to die and stop costing them money. Before the ACA, they would try to kick them off their books and then deny them insurance on the grounds of a pre-existing condition, but since they can't do that any more, trying to get them to die in a way that they can't be sued for malpractice would suit them very nicely thank you very much.
This brings up a problem with American health care in general. The standard 15-minute appointment does not allow for the true exploration of alternative treatments. My experience is that I am offered alternatives less than 20% of the time. Generally speaking, the doctor simply makes a recommendation.
My ordinary practice is to accept the recommendation and when/if it fails, to go on to the Internet to get a broader picture of the options that exist. Of course, I'm internet savvy enough to recognize responsible sources of medical information and read scientific papers.
I sympathize with the argument here but I'm not sure Noah's proposed remedies are completely on point.
In countries like Canada and the UK where health care costs are socialized, there has to be some sort of collective decision about which treatments justify themselves on an expected cost/benefit basis. The availability of MAID shouldn't affect that calculus, but it does have to be performed.
So it's not clear that the Canadian cancer patient's doctors made the wrong decision. It sounds to me as if their rationale was "This chemotherapy is very expensive and it will only lengthen your life by a few months at most, so we won't pay for it... and by the way, you should consider MAID". That's very different from saying "we refuse to treat you •because• you can painlessly kill yourself, so do that".
Average waiting time for a medical procedure in the UK is now down to 37 months, actually. So . . .
I have treated many people with clinical depression and find your article very worthwhile as an account of the real problems in their or their agents making any decisions which require capacity. Fwiw, I should state my position on assisted dying - I am in favour of it in extremis though not outwith a legal and ethical framework (easier to say than conceptualise).
You use the terms interchangeably, but medical aid in dying and euthanasia are slightly different things. In medical aid in dying, the party who wishes to die must decide independently to go through the process and self-administer the medication cocktail which will cause them to die, whereas in euthanasia, someone else can in cases make the decision and someone else can give the medication to the person (who may in cases be comatose or otherwise unable to self-administer). In the US, only medical aid in dying is legal.
Doctors are not the only ones who face mixed incentives on the issue of assisted suicide. Some close human relationships are blissful, and the thought of death is agony. Other relationships have difficulties, and the thought of release has attractions. Clint Eastwood's film “Million Dollar Baby” was a great contribution on the issue.
I had my own experience with a relationship that was both rewarding but increasingly difficult. Over 20 years ago, I met a man who had become an alcoholic at nine years of age, by finishing up the booze left around the house by his alcoholic mother.
He was a brilliant man with whom one could discuss any topic with pleasure and profit. He was also warm and affectionate. He had a buoyant, childlike enthusiasm and was a total sucker for stuffed animals.
For a while, he cut down on his drinking very significantly. The last two years I knew him, however, he went into a sharp decline. His ability to control his drinking and emotions decreased dramatically. His outburst of rage became sudden and unexpected.
We had enjoyed going on trips together. I invited him to a final trip to Maine, 2,000 miles from my house. I thought to myself, “If he can behave himself, we'll have a great time. If he can't, I will leave him far from my house without guilt because I know he has the smarts to care for himself."
I left Charlie in Maine in August 2006. He died of a heart attack in a homeless shelter in Maine in January 2007. I admit that my first reaction was relief. In his case, it could be said with confidence that he was in a better place, inasmuch as planet Earth clearly lacked the resources to address his pathologies.
Charlie was buried in a rural graveyard near Carthage TX where one quarter of the graves shared his last name. His family warmly thanked me for “What you did for Charlie.” Charlie is buried next to his mother, whom he had nursed through her final months with cancer. In his grave I placed a large stuffed monkey, representing Charlie, hugging a small yellow chick representing his mother. To this day, from my bed I can see my souvenir of Charlie: a tiny enthusiastic stuffed duck with big eyes and boundless irrational exuberance.
Even though I am religiously opposed to suicide, I would have been tempted to agree to suicide if Charlie had suggested it during those last two difficult years. So, it is not only doctors but many, may close friends and relatives who will face tormenting dilemmas and competing motivations.
"First, there’s the possibility that people could simply be denied life-saving treatments if health providers consider MAID a cheaper, acceptable alternative. The moral justification for MAID is based on the idea that people should get to choose when to die with dignity. But some people don’t want to choose death. If a health care system makes that decision for them, refusing to pay for non-MAID care, it has violated the principle that death should be a choice.
For example, here’s a story from last year about a Canadian woman who was given a poor abdominal cancer prognosis and urged to die with MAID instead of getting surgery and chemotherapy. She refused, and went to the U.S. for treatment. Canadian health insurance refused to pay for the treatment:"
But this is how most big government health care programs operated, even before euthanasia considerations. They certainly don't pay for little hope extraordinary measures that are much more common in the US. And in fact one area where European health systems lag in survival is cancer care, because they've been trying to economize on care for years.
In Oregon we have a long standing program of death with dignity. My first husband used it when he had ALS. He was very grateful to have the option. In Oregon, participation is limited to those with a fatal illness. The patient must request it themselves and must meet criteria to show that they are able to make an informed decision. I’ve not heard of any misuse of the program. It is used each year by several hundred people. Studies have shown that people who choose this path like to control their lives.
First an important clarification. Canadian doctors are not allowed to mention or otherwise bring up MAID as an option. Other health care providers possibly but not doctors. The woman with cancer would have been offered palitave care if she was facing cancer without a likely treatment. There is a growing thought that spending the majority of your final days undergoing painful treatments to extend your life only a little. For example would you want to live 13 months instead of 12 if you had to spend half that time in hospitals? They do the best with the information they have.
Depression is often resolvable, not always, and as such there will be a lengthy process before MAID is accepted by the doctors, not just one but two have to sign off.
In Canada doctors are in the top 1% of earners, need to be a bit isolated from the problems of every person they see, generally getting older and might just be out of touch with the person sitting in front of them so they can't always be the fountain of compassion we might all need. From my own experience doctors like to work on thing they can easily fix. 3 years of testicular pain near a dozen doctors (some just filled th eperscription I asked for) and 2 specialists later I was greated by a doctor with "so are you filling out the paperwork for a gun (inturupts) it doesn't matter I couldn't help you anyway." He didn't really think I should go home and buy a gun (not an easy task in Canada) but this was his unsympathetic way of ensuring I didn't come back. 5 more years later and well you learn to live with (and avoid doctors) it but it would have helped if just one of them had offered anyting that might have made it easier to live with sooner. I was quickly screened for cancer and then well you are often on your own.
I 100% share the concerns about euthanasia/MAID, and the extremely difficult interface with mental health.
But the financial incentives here are absolutely not so simple as presented. For doctors and hospitals it is almost entirely backwards, in Canada at least. A large portion of a medical costs accrue in the last months of life. That is income for the doctors and hospital. They are are fee-for-service in large part. Healthcare would not have constant budget issues if doctors were generally incentivised not to treat, rather than the opposite. For the payors, the state and insurers, there is a weak incentive to get euthanasia rates up. But they can't reach down into individual consultations. I say weak incentive because you have to ask whether a state administrative bureaucracy really has an incentive to shrink its own budget?
In the UK (where I have researched healthcare costs at the end of life). There is much less fee for service for doctors, so they do not have a contrary incentive. However, there is still no incentive for them to save the payors money by recommending MAID. And hospitals are still fee for service in an internal market structure so they are incentivised against.
Dear Noah,
Euthanasia is on the radar, and quite well guarded. However, under the radar is the "letting go" of patients. Deciding to not start a new treatment and so letting the person die. Or more often than not, staying in the zone where no decision is taken, and the person slides away. It is in this zone where incentives can do their perverse magic.
The problem with euthanasia is "if you are in your right mind". When some people age they lose cognitive recognition. We write health directives that specify "do not resuscitate" . I want a mental directive that says when "I can't recognize my spouse and/or kids I want to die"
“If you disagree with that — if you think that all human life is sacred and should be preserved and protected at any cost, or even if you just feel like there’s something wrong with euthanasia that you can’t quite express — then fine. I respect that viewpoint. That’s not the debate I want to have today.” Thank you, truly and sincerely. I am a devout Christian and someone who deeply believes this. I love so much of what you have to say. I spent a career in finance and was initially drawn to your Substack (actually, even prior to you making that transition) by how fresh your economic insights were. While I am likely not as smart as you I am smart enough to know that you are exceedingly sharp. I am also kind of astonished at the amount of information you consume and your output. I used to think this about Paul Krugman until he became, well, a bit rabid. I do not consider myself right or left. That is a distinction that makes arbitrary and unnecessary dissections and rather like making a big deal about whether you drink Seven-Up or Sprite. I have wondered at times whether I would be able to continue to be a part of this little community you’ve created. I know you don’t agree with me on the deepest questions but I’ve wondered whether you would consider me less reasoned for that. I find that to be a somewhat odd posture for many of my elite friends. I am afraid they drank a little too deeply from the well that their professors served them at institutions that were overwhelmingly started by people largely like me, regarding the deep questions (see: “God and Man at Yale” Buckley). My church is literally full of PHD students and professors from UC Berkeley. I know you went to Stanford, that notwithstanding, I think we would have to conclude, objectively, they’re not idiots. We’re not idiots, you’re clearly not an idiot. Let’s shelve that and see if we can get a few more years out of this deeply flawed and terribly beautiful experiment known as America.
Peace,
I appreciate your candor regarding depression very much. 🙏 I hope it's a battle you always win.
My mother is in the advancing stages of Parkinson's. Ive watched my father in law drown in his own fluid in hospice due to cancer. My fathers, mother in laws, death were sudden and in retrospect, a blessing. 3 siblings as a family have struggled to keep up with my moms care needs. It's been emotionally and physically very difficult. It's not an end you would wish on an enemy. I support assisted suicide. If you've ever been in a care home, or nursed an elderly person, the loss of independence can be a prison to them. Particularly the loss of the mind. I sat in on a discussion with my moms neurologist about what would happen to her body over time. It was devastating and not something I'll ever forget. The weight of care is societal. I'm not even sure how to quantity it.The vast # of care workers and nurses are phenomenally compassionate. As an agnostic, it's God's work and the most human kind of care. I'm not disgusted by Parris' argument. It's cruel but frank.
Stringent metrics, familial input, checklists, client directives are essential. Real compasion.
We already treat each like commodities. A discussion about humans as a natural part of an ecosystem that brings death back into the picture in a world that has tried to avoid the topic, particularly in wealthy countries would ground us all. Particularly younger generations. It can be a profound teaching moment about how we live, love and choose to die.