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.
I would self-examine your response here for wagon-circling. Not every criticism of your country's policy is a moral panic. This one definitely isn't.
The perverse financial incentive is absolutely there, and you shouldn't just refuse to think about it.
The autistic woman probably wasn't given MAID for being autistic (though the reason she was given MAID hasn't been disclosed, so you're making an assumption). But the fact that she's autistic might make her mentally incapable of understanding the difference between a doctor's recommendation and a simple offer of information about her options. That's something you should consider.
The question here is not whether people should be "forced to live a life of suffering". No one is being forced to live. The question is whether doctors should recommend death to people who aren't qualified to decide whether death is a good idea. And the question is whether insurance should be able to deny people coverage for alternative treatments, thereby insisting that poor people choose death as their only financially available option.
Simply repeating the basic moral case for euthanasia, which I already accept, doesn't address any of these points. It's just wagon-circling.
Not every argument against your position is 'wagon-circling', that seems like a way of cutting off debate. But regardless:
I concede it is possible for someone to have autism so severe she cannot meaningfully consent to MAID. I make this point in my response – 'what matters is the capacity to make the choice – and depression may be disqualifying then'. This court ruled that her autism was not that severe.
I also agree that doctors should not be 'recommending death,' but I do not see much evidence that is happening. It's fine to mention MAID as one part of preparing for death, but no one should be denied treatment for which they would otherwise be eligible. If this is in fact happening it should be extremely illegal, all treatments should be the same as if MAID did not exist, unless the patient opts out of them with informed consent. In the Canadian system, certain treatments are simply denied because they do not have enough chance of success, regardless of MAID.
I am not sure, but since you mention insurance, which essentially is not part of the Canadian health system, you are picturing American insurance companies using the profit motive to recommend death, and indeed in that case MAID is way more problematic. In Canada the financial incentives tend to play out more at the policy level but again – is the existence of that perverse financial incentive enough to deny me what I see as a fundamental right? Like I say at the end, if the existence of MAID excuses chronic underfunding of the health system that would be a huge point against it for me.
I also am not sure you do concede the moral argument for euthanasia, or at least its stronger version. Do you think that I, being of sound mind, have the right to choose it for any reason I see fit, or is it limited to certain cases where the government agrees MAID is appropriate, such as terminal illness? If the latter we don't agree on the moral argument.
If I were trying to cut off debate, I wouldn't have written a detailed response! :-)
"I concede it is possible for someone to have autism so severe she cannot meaningfully consent to MAID." <-- I honestly don't know if people can or not. But I'm not confident that this is being addressed in a systematic manner. The court system definitely seems like the wrong place to adjudicate that; there needs to be a review process in place that happens every time.
"I also agree that doctors should not be 'recommending death,' but I do not see much evidence that is happening." < -- Did you read the part of my post where I talked about how when doctors offer a treatment, it's automatically a recommendation?
"I am not sure, but since you mention insurance, which essentially is not part of the Canadian health system, you are picturing American insurance companies using the profit motive to recommend death" <-- Americans use the term "insurance" to mean "whoever is responsible for paying for health services". So yes in this case I meant the Canadian health system that denied payment to that woman.
"I also am not sure you do concede the moral argument for euthanasia" <-- It's not a concession. I just believe it's right, and I always have. For it to be a "concession" would imply I had some reason to argue against it. I do not.
"Do you think that I, being of sound mind, have the right to choose it for any reason I see fit" <-- You can always just commit suicide; no one can really stop you. The question here is not whether you have the right to do it. It's whether doctors ought to suggest it to you. And do I think doctors should suggest that you, with no condition that puts you in unbearable pain, ought to suggest suicide to you? No, I definitely do not. Do I think that you should be able to walk into any clinic and demand suicide as a service from the clinicians? No, but only because it's a waste of money.
re: cutting off debate, fair enough! I appreciate you taking the time to respond and I think we're honing in on specific areas of disagreement.
On adjustication, I think we agree. In this case it went to the courts but ultimately needs to be some standards on which this is judged and doctors need to be part of this process. It also needs to be on a case-by-case basis. I am fully open to the argument that the current systems are too permissive on this.
On the financial incentive, I understand where you're coming from, but the system already has these dynamics built in. Financially, recommending MAID is already more expensive than simply denying treatment, which is what many US insurance companies do. In a single-payer system a lot of these cost-benefit decisions already get made, some heartbrakingly, and I don't think MAID changes this substantially. Perhaps doctors who would never withhold treatments feel comfortable recommending MAID for financial reasons, but I doubt it. I suppose you and I differ on the impact of the financial incentive and your evidence seems somewhat anecdotal to me.
I misinterpreted your point on doctor recommendations, but I disagree you as you've stated it here. A doctor has a responsibility to lay out all options. Right now, that can include end of life care, or simply forgoing treatment. MAID can be part of end of life care. I do not agree that simply mentioning options to a patient is a recommendation. If the adjudication of competence is working as intended, I do not think this is a problem. However, I agree that doctors should only mention MAID in contexts where it is appropriate, like terminal diseases or severe chronic pain. They should still advise if the patient asks about it themselves.
Finally, I think we agree on the 'right' to suicide in that I have the right to jump off a bridge at any time. We disagree on how it fits into the medical system. I see euthanasia like the famous line on abortion: it should be 'safe, legal and rare.' It should not be encouraged but I do think it should be treated like a medical procedure, so people can die with dignity. Most forms of suicide available to me are undignified, hence me supporting the availability of MAID as part of the government system.
“Roger Foley, who has a degenerative brain disorder and is hospitalized in London, Ontario, was so alarmed by staffers mentioning euthanasia that he began secretly recording some of their conversations.
In one recording obtained by the AP, the hospital’s director of ethics told Foley that for him to remain in the hospital, it would cost “north of $1,500 a day.” Foley replied that mentioning fees felt like coercion and asked what plan there was for his long-term care.
“Roger, this is not my show,” the ethicist responded. “My piece of this was to talk to you, (to see) if you had an interest in assisted dying.”
Foley said he had never previously mentioned euthanasia. The hospital says there is no prohibition on staff raising the issue.”
I think we agree on more than you thought we did at first! ;-)
By "wagon-circling", I just mean the instinct to defend one's own country's policies when a foreigner criticizes the system. I get the same urge when Europeans criticize America... ;-)
*Which* America? During the pandemic, my wife and I used to joke that Red State America was enthusiastically cutting medical costs by using Covid to kill off the more infirm portions of their elderly populations, by discouraging vaccination, masking, etc.
I don’t understand the personal freedom argument. As Noah said, you have the right to suicide, but the fact that you’re seeking a doctor’s participation is enough to show that this isn’t about personal freedom. No one has the right to the medical treatment of their choice. The state is perfectly within its right to ban harmful medications entirely, or to restrict them to desperate or terminal cases.
Something that requires professional medical help can obviously be a matter of individual freedom. Abortion may require medical help, and yet, it is a matter of individual freedom. The individual freedom part is about the individual making the decision about their own body, not about them doing the operation themselves. The state has the right to ban medical treatments and diminish individual freedom, or to legalize them and expand individual freedom, and clearly there are several different values at stake, and all of this is socially/politically negotiated.
Saying that people have the right to kill themselves is not a compelling argument as to why people should not have access to medical help for suicide. Doctor assisted suicide is painless and dignified, unlike common suicide. While I am strongly in favor of euthanasia for the classic cases, I agree with much of what Noah said, so I am honestly torn about how expansive euthanasia should be.
The argument against allowing MAID is the one Noah gave: there are perverse incentives which over time will lead to unacceptable abuse. The consequence is that people who really ought to have MAID will be denied. I, too, am unclear what should be done. There is an old legal saw "Hard cases make bad law" which comes to mind.
This is an old thread, sorry I missed it. As a Canadian physician and former member of a “medical board” (we call them Colleges) I can say that the balance between offering false hope and risky treatments vs scientifically valid but compassionate care is tricky, and not every MD gets it right. In the Canadian context, anecdotes are anecdotes and cost does not come into the discussion, unless a treatment is simply unavailable.
Its always better to read the actual decision than the media articles. And much better than reading the foreign headlines which bent backwards to imply that this was a healthy minor being MAiDed for being autistic.
Thank you for the link. I agree with your advice about reading the source material. I maybe wrong (I often am), but the legal case seems to reinforce Noah's argument: MV was allowed to undergo assisted death because she chose to. MV did not present any medical grounds for why she wanted MAID and refused to rebut the medical evidence from her parents that her only established condition was Autism (and ADHD). The judge decided her decision-making rights and the fact that 2 MDs authorised it was sufficient. So to stoke the moral panic - it seems this is an example where creating a social pressure to die if you are unhappy (or inconvenient to society) and a financial incentive to the medical establishment will result in people dying 'before their time'.
And who is "qualified" to decide if I should have the right to make that decision? You insist this isn't a slippery slope argument but it is just that. There is, for example, a difference between a depressed teenager and a depressed 80 yo who has lost both a spouse and children. You may think that 80 yo isn't capable of making that decision, but what gives you or the govt that right? Is abuse possible? Yes. But I don't want my choices curtailed because of an unquantifiable but probably very small likelihood of abuse.
Yes, choice should be curtailed. You can spend your time on earth helping others if you are so personally miserable you have nothing to live for. It sounds harsh but it’s the truth- suicide is an irreversible choice and not a victimless act.
"The question is whether doctors should recommend death to people who aren't qualified to decide whether death is a good idea"
This is NOT the question. No one, least of all doctors, want to 'recommend death.' MAID scrupulously screens applicants to ensure they are acting of their own volition. The Dutch system, which should also be included in the models being used, reviews the process after every death.
Nor is anyone suggesting 'insurance should be able to deny coverage for alternative treatments.'
The Canadian, and much longer running Dutch, examples show that this option is used by a small number (4% in both countries, interestingly), of relatively high-income educated types.
The goal is to drive policies in parallel, manage a humane end-of-live hospice network and home care system (probably for the vast majority - 96%), AND offer assisted dying as an option to those who ask for it.
More research on all the countries that offer it and their different approaches is here:
Given that I'm the author of the FORBES piece, and that in my column there I can publish pretty well what I want, I'd suggest profit margins aren't the motivating factor here.
And that a 61-year old with hearing loss almost certainly wouldn't pass the review by the 2 doctors necessary to access Canada's MAID system.
Asking the government to grant you the opportunity to kill yourself, and the resources to do it is not a matter of individual freedom. If anything, it’s the opposite- a sort of eugenics and definitely anti human policy.
Suicide IS the wrong choice in like 99.999999 percent of cases. In the others, you are the Iron Giant and sacrificing yourself to save the world. There are some people who are terminally ill and elderly and that is one thing worth debating, if you are physically healthy and / or have a treatable condition you should not Jill yourself, period end of discussion. Even if you think you have nothing to live for there are others who want you alive and you should stay alive for them.
Michael Moss writes: " insurance, which essentially is not part of the Canadian health system" I myself live in the most populous province of
Canada, Ontario; and through my taxes I pay into something called the Ontario Health Insurance Plan. Of course it is insurance. It's very name says it is insurance. Plus there are many health conditions and expenses which the tax-funded OHIP does not cover, and for which people take out private insurance as well. Plus many well-to-do Canadians take out additional private insurance so that they can get treated in the US when the OHIP bureaucrats say that this that or the other thing is not covered. I strongly strongly resent the ill-informed contention that somehow Canadians benefit from a universal all-inclusive health care system, from cradle to grave that is even as generous as such programmes as the American Medicare system. And yes, it is certainly the case that the bureaucrats who administer the Ontario Health Insurance Plan take into consideration what might be called "cost effectiveness" in deciding which medical procedures should be covered and which not. Whether this involves refusing to fund expensive care on the grounds that the patient may be expected to die soon, I do not know.
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.
Sadly, this article sums up what I was just saying this to my mother the other day as we talked about what will happen to the increasing hordes of childless adults when they reach their senior years. "They're going to tell us to kill ourselves. And most people will be depressed enough to do it." :/
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".
Triage is happening, regardless of how much we might want to ignore it. In the US, it just isn't being done in an organized, rational manner. A few years ago, a friend's 94-year-old mother fell and broke her hip while being given a shower in a care facility. She had been bed-ridden or in a wheelchair for at least a decade. A doctor saw an "opportunity" with her injury and recommended a Medicare-reimbursed $250,000 platinum mesh repair procedure that produced no change in her capabilities at all. She died less than a year later.
I actually think Noah’s last suggestion--that healthcare providers should be prohibited from suggesting MAID unless the patient brings it up first--would more or less solve the problem. "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" is always going to feel linked to the patient, whether it is or not. Just say the first part, and the patient can draw their own conclusion about whether or not they want to die as a result. This risks missing some patients who don’t know about MAID or think they wouldn’t be eligible, but that can be partially solved with a general education campaign and imo is far better than the alternative where people may be coerced. Euthanasia should be available to those who really want it, and those people will suggest it themselves. There’s no need to expand it to those who only kind of want it.
Exactly. In the UK, many (expensive) treatments are already being denied on a routine basis. NICE evaluates all taxpayer funded treatments based on cost and financial impact.
Even without assisted dying as an option, plenty of people are denied free treatment. Their alternative? Less effective treatments, or higher chance / quicker death.
Assisted dying just adds an additional option for patients, when a treatment is not possible or denied based on cost/benefit to the country.
But I don’t think you’re seeing Noah’s point that when this “additional option for patients” saves the state money, then it is incentivized to expand its use, and the actual treatments become harder to justify when a cheaper option (death) is available.
This argument arguably proves too much, though, because presumably the cheapest option is just "don't provide any healthcare, period." Doing nothing will always be cheaper than doing something. The BATNA to both providing expensive treatment *and* to euthanasia is "do nothing."
Put another way: if the state were really concerned about saving on healthcare costs, the cheapest option would be "don't provide state-sponsored healthcare" or "don't provide state-sponsored healthcare to anyone over 65." The fact that there's non-zero public care provision is the result of a political determination that it's important to provide such care, not some kind of law of nature. So if a political determination is the only reason that more-than-zero healthcare for old people exists despite the fact that it's more or less negative EV in and of itself, why are we concerned about the diminution of that political will in particular circumstances to save cash? If saving cash were the primary determinant of system structure and expenditures there wouldn't *be* a public healthcare system for retirees in the first place.
Well, I think it's similar to why (say) authoritarian states have kangaroo courts. Why bother with the pretense, why not just deal with accused people extrajudicially? Because of a political determination that some pretense of process is required for legitimacy. Euthanasia is more costly and complicated than just throwing people in the street, but it has much more legitimacy and political palatability. So when the medical establishment is given access to it, they get access to a way to save costs in ways the public will perceive as humane rather than cruel. This provides an incentive to find more and more use cases for euthanasia. That doesn't mean euthanasia shouldn't be used at all, but it does mean we should impose strict safeguards to guard against that tempting "mission creep."
I also note that you're talking exclusively about the elderly and retired, but MAID is not just available for them, and a large part of the controversy involves cases in which its use is expanded to people who may have many years of high-QALY life remaining to them.
Your argument needs clarification. Not treating or delaying timely treatment of many or even most forms of early-onset injury and infection can result in vastly more expensive intervention(s) later. Penny-wise, pound-foolish. A stitch in time saves nine, etc. It's for this reason that even many insurance companies encourage some degree of preventative care.
Denying or delaying care for patients whose condition has "stabilized", is another matter entirely. Especially where further care for minimal or no gains is extremely expensive. A complex spinal surgery, for example, can cost roughly $250k from soup to nuts in total cost; and yet the odds of that patient needing a subsequent surgery are roughly 50%. These are the sort of patients that industry would love to disappear.
The "industry" here is the taxpayer given that Noah is addressing socialized medicine vs. euthanasia in Canada -- if they were profit-motivated they just wouldn't offer the care in the first place.
I agree that private insurers face a more perverse set of incentives (as insurers always do in every industry. The goal is to take premiums, not pay out claims), although if we're in a situation where we're talking about "further care for minimal or no gains" maybe we....shouldn't be doing that further care?
My professional experience was in managing mostly chronic inflammatory pain, where more often than not 'piling on' early with lots of resources in a multi-modal approach could more often than not stop or greatly diminish a subsequent cascade into secondary and tertiary pain patterns. A stitch in time really can save nine.
State-managed care systems like CA's Worker's Comp system by necessity try to contain health care costs that are outpacing inflation in order to remain solvent. They do this by trying to apply only 'best practices' up to and until the patient ceases to improve. A medical application of the law of diminishing returns. Then it all goes into a gray zone, where the patient has to self-advocate for further care. Determining what will or will not help these patients is truly the frontier of medical practice.
The problem is where subcontracted private insurance "specialists" are brought in to help "manage" patient care, as they already do in private PPO's/HMO's. My overwhelming impression was that they would deny any and all care if they could; not just when a patient reaches the stationary phase.
I think if many health providers are pushing terminal patients to kill themselves rather than, say, putting them in hospice care, then we have far deeper problems with how such health care providers are trained and how they understand their role in society than how much they respond to financial incentives.
I think they have to swear some oath or something, I once heard.
The question is whether the availability of MAID did or didn't influence Canada's decision that the cost of the chemotherapy wasn't justifiable. It didn't sound to me as if it did, so it's hard to tell whether that case raises a valid concern.
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.
Not sure it's a problem with _American_ health care in particular: more likely it's a global shortage of doctors because so many retired early after suffering burnout during the Covid pandemic.
In fact I'd say the US is probably doing better with doctor availability than European countries (albeit at the cost of health care becoming increasingly unaffordable) as it wins the global bidding war for medical staff.
I only wish the US was winning "the global bidding war for medical staff." Rural areas are being depleted of any sort of available medical professionals or even facilities. The Reagan era move to glorify "unearned income" over earned income has siphoned at least three generations of our best and brightest into useless financial manipulations, leaving the country short of doctors, scientists, engineers, teachers, and other critical professionals. Vilifying government experts and others who have dedicated their careers and lives to science and analysis hasn't done us any favors, either.
I guess I'm looking at things more from my UK perspective: the NHS has long depended on third-world immigrants to staff it because such a large fraction of Britons who qualify as medical doctors chase after higher salaries in the United States or Australia.
This seems a bit problematic, "to go on to the Internet to get a broader picture of the options that exist." The Internet is not a place one should be spending time researching "alternatives" to doctor-recommended treatment, namely because there's little-to-no data on the efficacy of those treatments and in reality - almost none of them work. My husband is a medical oncologist and the agonies he's experienced from patients determined to do everything to avoid his recommendations who then head to quack clinics in Germany vs. undergoing specific, targeted therapies for treatable cancers are legion. Any patient can and should be an active partner in their treatment plan for whatever illness they're experiencing. But medicine shouldn't be a buffet-style restaurant where one picks and chooses from a plethora of options when many of those on offer are akin to snake oil or worse.
My top sites for web research are the Mayo Clinic website, Johns Hopkins website, the Cleveland Clinic website, and WebMd.
I am generally quite enthusiastic about mainstream medicine. The number one problem is that the doctors I encounter don't seem to be aware of all the treatment possibilities that exist within mainstream medicine.
For example, one very important part of my daily pill regimen is a treatment that has been standard for 60 years in Germany (very mainstream there) but is hardly known in the United States. I brought it up with one of my best doctors and asked why he did not recommend it. He told me that he used to, but it didn't work for everyone.
I am much more careful in evaluating “alternative” treatments, but I have found at least one that dramatically reduced my cholesterol levels consistently for over 10 years now, from 200 to an average of about 140.
Generally speaking, I'm not a fan of Bing, but they have an AI program called Copilot that is very good as a starting point for Internet research focused on mainstream medicine. Copilot leaves Chat GPT in the dust. The button is located in the upper right-hand corner of the Edge page.
No. Chat GPT and Copilot are completely independent of each other. They are the same type of program but have completely different origins. Mercedes and BMW's are both cars, but they are not the same.
Not necessarily. "Garbage in, garbage out," is far more likely for anything but the simplest diagnoses. Especially if there's a profit motive that encourages/discourages either specific treatments or denial of care.
A far more likely scenario is that that AI will begin to replace health insurance adjustors and care managers, who are already reflexively likely to deny and/or delay care.
"Medical Necessity" is where the rubber meets the road. In clinical practice this can be a very fluid concept, especially in acute conditions. Insurance companies now track physicians who prescribe too many treatments or diagnostic procedures that the industry considers unnecessary or overly expensive compared to alternatives, and will drop them from their provider rolls as a consequence. In CA this appears to be a growing trend.
This is a source of extreme professional stress for medical professionals. In California, at least. Talk to any MD or nurse who works in a hospital or managed care setting if you don't believe me.
PS I am in total agreement with you that most alternative therapies have not been researched to the point that would make me happy. And I also agree that cancer patients are peculiarly desperate and willing to grasp at any shred of hope.
Having been an Alternative Medicine provider in CA for 25 years, my experiences largely validate your conclusions. Modern medicine in today's America is mainly a huge turf-fight for $$$ between the three dominant stakeholders: Big Pharma, Health Insurers, and the AMA & Nurses Unions.
Many quite effective Alternative Medicine treatments and therapies are quite frequently ignored or overlooked in favor of the often far more expensive conventional methods. And this includes cancer.
A basic problem is that natural occurring materials cannot be patented and become the source of great profits. Accordingly, they don't get researched. My total cholesterol has been dramatically and reliably reduced for the last 10 years by a combination of berberine and cinnamon extract. I've gone from 200 to 140.
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).
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.
Your comment telling the story of Charlie is an important contribution to this issue. To watch someone close to you suffer with minimal or no hope of improvement is painful when a release from suffering is not legal. As Noah wrote, it seems as if euthanasia is likely to continue to spread so regulating it so that individuals are not stripped of agency by the medical profession is very important.
I downplayed the fact that Charlie could be very scary when he flew into a rage in his last two years. 99% of the time he confined himself to destroying inanimate objects but that doesn't make a vulnerable woman feel much better!
I did have an order of protection against him at one point. It was clear that a physical separation was the best solution. But I still always loved his good side, which was quite extraordinary. I agreed on this statement with someone who knew him well: "He was much better than average and much worse than average—the only thing he wasn't was average.”
Six years ago my wife was suffering the last stages of terminal lung cancer. The pain had become so unbearable that we were exploring ending her life via California's death with dignity law. It was at that moment that a random California Superior Court judge put a stay on the entire law for the most incredibly specious reasons (saying the law couldn't be passed during a special legislative session).
I cannot tell you how devastating that decision was for us and how I believe it contributed to a spiraling down for her, followed by an ugly and horrific death two weeks later, a memory that curses me to this day.
Clearly, we need to police death with dignity laws along the lines Noah proposes. But we have to stand fast and hard against actors who would use horror stories like he relates to take away something so often vitally needed. This kind of law, properly administered, is humane and a sign of a wise and caring society.
I'm so sorry to hear about what you and your wife went through. We should strive for a balance. Families should be protected from both doctors and courts.
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.
"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.
The alternative explanation is that US cancers are diagnosed earlier and more frequently, which would raise life expectancy after detection even if actual outcomes were unchanged
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.
Except they DO bring it up, and patients are too fearful of repercussions to report it. I realize this is anecdotal, but I have had three close friends with treatable but chronic conditions bc offered MAID, even though they were trying to get stable / get adequate care. One was even told they were a burden on the system. By the attending.
I’m all for dignity in dying, but it needs to have safeguards so it is not used as a bludgeon for people who want to live.
In this regard rules are only as good as their enforcement. We should feel more comfortable filing a complaint against a doctor. I know one person that did and it took some time and frustration, it wasn't over MAID.
Being told you are a burden is being a highly paid @#$ but is not the same as suggesting MAID.
Perhaps you haven't been put in the position where there's a limited amount of specialists for your condition. In this case, filing a complaint for this issue would only cause more challenges to care — care that is already sorely lacking.
Perhaps my comment was insufficiently clear: they were told they were a burden AND that they ought to consider MAID.
Indeed, it isn't often the same — which is the point Noah made in this piece, and what I was reiterating in the comments. Disciplinary reports are not safeguards by any means; they can help in some cases, but in the experience of the vulnerable patients I hear from often, they only further penalize the people seeking care. More is needed.
It is indeed a system that needs improvement. Somethign this seriouse and important should never seem settled. My wife's a nurse and much more knowlegable on this but I'm pretty sure the doctor or doctors that have suggested MAID are not likely the same doctors that will actually carry it out. It also takes more than one doctor to sign off.
"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."
Generally palliative care should be offered much earlier than it normally is. There was an important New England Journal of Medicine article years ago showing survival was longer in the patients given palliative care along with their standard care for colon cancer vs. just standard care.
A lot of this concerns the pendulum-effect attitude towards opiates here in the US, where we have gone through cycles of over- and then under-prescribing opiate analgesics.
The role of the insurance industry in directly and indirectly "encouraging" MD's to deny Rx. care is also a substantial and worsening trend.
“Canadian doctors are not allowed to mention or otherwise bring up MAID as an option.”
Where do you see that? This article (https://apnews.com/article/covid-science-health-toronto-7c631558a457188d2bd2b5cfd360a867) says the opposite: “The Australian state of Victoria forbids doctors from raising euthanasia with patients. There are no such restrictions in Canada. The association of Canadian health professionals who provide euthanasia tells physicians and nurses to inform patients if they might qualify to be killed, as one of their possible “clinical care options.””
My wife's a nurse here in Canada and this is her responce and a few links.
"Physicians need to tell patients that their condition can no longer be treated or treatment can cause harm versus benefit and a palliative approach is more appropriate. Patient can continue to request futile treatment and receive it until their capacity is impaired. It is hard for people to hear that there isn't much can be done for the condition or risk for harm is too high. "
So if you have a treatable condition they shoudl not be bringing it up. If you condition is not treatable they should bring it up I supose.
"qualified to be killed" suggests some bias in your opinion around this.
Thanks for sharing these. However, I don't see anything in your wife's statement or in either of the links (granted I did not read them thoroughly since they're both quite long) that says doctors are not allowed to raise or suggest the topic. One of the links did say the decision to die cannot be the result of external pressure, but as far as I can tell that does not prohibit doctors from mentioning it, as you said. If I'm missing something, please let me know.
"Qualified to be killed" is part of the quote from the AP article, not my own words. The article is clearly skeptical of assisted suicide for people with non-terminal illness, and so am I; you could call that a "bias," but in that case anyone who holds an opinion is biased. Lots of people in these comments spoke of how they wished they had assisted suicide available to relieve suffering of ill relatives; is that a "bias" that they should strive to eliminate or else not comment? But in any case I'm not sure if I even see what's objectionable about "qualify to be killed." If someone is administered fatal drugs, are they not killed? What would be a more acceptable term?
I think I conceeded that if you have a non treatable ilness the doctor should be telling you your options. A little different than the fear mongering that doctors are looking for people to kill. Noapinion's article could have done a better job of spelling out the process.
If someone is killed it implies some blame doesn't it, the doctor killed him is a better attention grabbing headline than a doctor helped someone end theri suffereing from a terminal illness.
I hadn't understood that you were withdrawing the claim "Canadian doctors are not allowed to mention or otherwise bring up MAID as an option." Sorry if I misunderstood.
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.
“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.
FWIW, I’m an atheist and I’m happy you’re here. It’s good to be challenged by people with different opinions and worldviews, as long as everyone argues in good faith, rather than be stuck in an echo chamber. I hope you’ll stick around. 😊
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.
Also, I just went back and read that Matthew Parris quote, yuck! Embarrassed by my country's 'intellectual' class spouting nonsense in the Op-Ed pages once again...
The role of the insurance industry in "encouraging" physicians to deny care in the US is not being addressed in this article. Here in CA, medical doctors can and are dropped from reimbursement from specific plans if they are deemed to "overprescribe" treatment. For doctors not practicing in boutique cash-only practices this can be devastating.
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"
It feels terrible to talk about fiscal costs, but it's a reality just as much as the human situation. I am grappling with this right now, having just moved my mother into memory care due to rapid progression of her dementia. Until you've dealt with it, you can't fathom how ugly and expensive it is.
My mom's memory care isn't covered by insurance and costs approximately $96K per year. She is currently on her second stint in geriatric psych to try to find a medication combo that will enable her to stay at memory care, as the dementia is causing a lot of fear/agitation and inappropriate behaviors to staff and other residents. If we can't stabilize her, our next alternative is either to keep her in geri psych until she dies, which is costing Medicare thousands of dollars per week, or possibly to sedate her to the point where she's manageable in the skilled nursing facility, which is $180K per year. The only other thing to do would be for one of us kids to quit our jobs, move her into our home, and devote ourselves to trying to provide 24/7 care -- and I do mean 24/7, she wanders all night, falls constantly and is a danger to herself and others.
I love my mother and will be gutted when she dies. I also wish every day that she will not wake up so that this will be over for her. She would not have wanted to live like this, but it's how she will likely continue to live for the next year or two of her life. She will die in indignity and quite possibly after undergoing a lot of pain and fear. And I don't know how in the world we'd be paying for it if our family weren't well off. It's all very well to say that finances shouldn't matter, but the enormous costs have to be covered for somehow, out of our own pockets, the government's, or our labor.
If she had anticipated getting to this point, and if MAID had been available to her, she would have chosen it in a heartbeat. If I'm diagnosed with Alzheimers one day, I know I will do it as soon as possible while I still have the capacity to make the choice. I won't put the emotional, logistical, or financial burdens that I am currently carrying onto my children.
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.
I would self-examine your response here for wagon-circling. Not every criticism of your country's policy is a moral panic. This one definitely isn't.
The perverse financial incentive is absolutely there, and you shouldn't just refuse to think about it.
The autistic woman probably wasn't given MAID for being autistic (though the reason she was given MAID hasn't been disclosed, so you're making an assumption). But the fact that she's autistic might make her mentally incapable of understanding the difference between a doctor's recommendation and a simple offer of information about her options. That's something you should consider.
The question here is not whether people should be "forced to live a life of suffering". No one is being forced to live. The question is whether doctors should recommend death to people who aren't qualified to decide whether death is a good idea. And the question is whether insurance should be able to deny people coverage for alternative treatments, thereby insisting that poor people choose death as their only financially available option.
Simply repeating the basic moral case for euthanasia, which I already accept, doesn't address any of these points. It's just wagon-circling.
Not every argument against your position is 'wagon-circling', that seems like a way of cutting off debate. But regardless:
I concede it is possible for someone to have autism so severe she cannot meaningfully consent to MAID. I make this point in my response – 'what matters is the capacity to make the choice – and depression may be disqualifying then'. This court ruled that her autism was not that severe.
I also agree that doctors should not be 'recommending death,' but I do not see much evidence that is happening. It's fine to mention MAID as one part of preparing for death, but no one should be denied treatment for which they would otherwise be eligible. If this is in fact happening it should be extremely illegal, all treatments should be the same as if MAID did not exist, unless the patient opts out of them with informed consent. In the Canadian system, certain treatments are simply denied because they do not have enough chance of success, regardless of MAID.
I am not sure, but since you mention insurance, which essentially is not part of the Canadian health system, you are picturing American insurance companies using the profit motive to recommend death, and indeed in that case MAID is way more problematic. In Canada the financial incentives tend to play out more at the policy level but again – is the existence of that perverse financial incentive enough to deny me what I see as a fundamental right? Like I say at the end, if the existence of MAID excuses chronic underfunding of the health system that would be a huge point against it for me.
I also am not sure you do concede the moral argument for euthanasia, or at least its stronger version. Do you think that I, being of sound mind, have the right to choose it for any reason I see fit, or is it limited to certain cases where the government agrees MAID is appropriate, such as terminal illness? If the latter we don't agree on the moral argument.
If I were trying to cut off debate, I wouldn't have written a detailed response! :-)
"I concede it is possible for someone to have autism so severe she cannot meaningfully consent to MAID." <-- I honestly don't know if people can or not. But I'm not confident that this is being addressed in a systematic manner. The court system definitely seems like the wrong place to adjudicate that; there needs to be a review process in place that happens every time.
"I also agree that doctors should not be 'recommending death,' but I do not see much evidence that is happening." < -- Did you read the part of my post where I talked about how when doctors offer a treatment, it's automatically a recommendation?
"I am not sure, but since you mention insurance, which essentially is not part of the Canadian health system, you are picturing American insurance companies using the profit motive to recommend death" <-- Americans use the term "insurance" to mean "whoever is responsible for paying for health services". So yes in this case I meant the Canadian health system that denied payment to that woman.
"I also am not sure you do concede the moral argument for euthanasia" <-- It's not a concession. I just believe it's right, and I always have. For it to be a "concession" would imply I had some reason to argue against it. I do not.
"Do you think that I, being of sound mind, have the right to choose it for any reason I see fit" <-- You can always just commit suicide; no one can really stop you. The question here is not whether you have the right to do it. It's whether doctors ought to suggest it to you. And do I think doctors should suggest that you, with no condition that puts you in unbearable pain, ought to suggest suicide to you? No, I definitely do not. Do I think that you should be able to walk into any clinic and demand suicide as a service from the clinicians? No, but only because it's a waste of money.
re: cutting off debate, fair enough! I appreciate you taking the time to respond and I think we're honing in on specific areas of disagreement.
On adjustication, I think we agree. In this case it went to the courts but ultimately needs to be some standards on which this is judged and doctors need to be part of this process. It also needs to be on a case-by-case basis. I am fully open to the argument that the current systems are too permissive on this.
On the financial incentive, I understand where you're coming from, but the system already has these dynamics built in. Financially, recommending MAID is already more expensive than simply denying treatment, which is what many US insurance companies do. In a single-payer system a lot of these cost-benefit decisions already get made, some heartbrakingly, and I don't think MAID changes this substantially. Perhaps doctors who would never withhold treatments feel comfortable recommending MAID for financial reasons, but I doubt it. I suppose you and I differ on the impact of the financial incentive and your evidence seems somewhat anecdotal to me.
I misinterpreted your point on doctor recommendations, but I disagree you as you've stated it here. A doctor has a responsibility to lay out all options. Right now, that can include end of life care, or simply forgoing treatment. MAID can be part of end of life care. I do not agree that simply mentioning options to a patient is a recommendation. If the adjudication of competence is working as intended, I do not think this is a problem. However, I agree that doctors should only mention MAID in contexts where it is appropriate, like terminal diseases or severe chronic pain. They should still advise if the patient asks about it themselves.
Finally, I think we agree on the 'right' to suicide in that I have the right to jump off a bridge at any time. We disagree on how it fits into the medical system. I see euthanasia like the famous line on abortion: it should be 'safe, legal and rare.' It should not be encouraged but I do think it should be treated like a medical procedure, so people can die with dignity. Most forms of suicide available to me are undignified, hence me supporting the availability of MAID as part of the government system.
Regarding recommendations:
“Roger Foley, who has a degenerative brain disorder and is hospitalized in London, Ontario, was so alarmed by staffers mentioning euthanasia that he began secretly recording some of their conversations.
In one recording obtained by the AP, the hospital’s director of ethics told Foley that for him to remain in the hospital, it would cost “north of $1,500 a day.” Foley replied that mentioning fees felt like coercion and asked what plan there was for his long-term care.
“Roger, this is not my show,” the ethicist responded. “My piece of this was to talk to you, (to see) if you had an interest in assisted dying.”
Foley said he had never previously mentioned euthanasia. The hospital says there is no prohibition on staff raising the issue.”
https://apnews.com/article/covid-science-health-toronto-7c631558a457188d2bd2b5cfd360a867
I think we agree on more than you thought we did at first! ;-)
By "wagon-circling", I just mean the instinct to defend one's own country's policies when a foreigner criticizes the system. I get the same urge when Europeans criticize America... ;-)
*Which* America? During the pandemic, my wife and I used to joke that Red State America was enthusiastically cutting medical costs by using Covid to kill off the more infirm portions of their elderly populations, by discouraging vaccination, masking, etc.
I don’t understand the personal freedom argument. As Noah said, you have the right to suicide, but the fact that you’re seeking a doctor’s participation is enough to show that this isn’t about personal freedom. No one has the right to the medical treatment of their choice. The state is perfectly within its right to ban harmful medications entirely, or to restrict them to desperate or terminal cases.
Something that requires professional medical help can obviously be a matter of individual freedom. Abortion may require medical help, and yet, it is a matter of individual freedom. The individual freedom part is about the individual making the decision about their own body, not about them doing the operation themselves. The state has the right to ban medical treatments and diminish individual freedom, or to legalize them and expand individual freedom, and clearly there are several different values at stake, and all of this is socially/politically negotiated.
Saying that people have the right to kill themselves is not a compelling argument as to why people should not have access to medical help for suicide. Doctor assisted suicide is painless and dignified, unlike common suicide. While I am strongly in favor of euthanasia for the classic cases, I agree with much of what Noah said, so I am honestly torn about how expansive euthanasia should be.
The argument against allowing MAID is the one Noah gave: there are perverse incentives which over time will lead to unacceptable abuse. The consequence is that people who really ought to have MAID will be denied. I, too, am unclear what should be done. There is an old legal saw "Hard cases make bad law" which comes to mind.
Yes, after I posted the comment I thought of the abortion example! I agree I put things simplistically.
This is an old thread, sorry I missed it. As a Canadian physician and former member of a “medical board” (we call them Colleges) I can say that the balance between offering false hope and risky treatments vs scientifically valid but compassionate care is tricky, and not every MD gets it right. In the Canadian context, anecdotes are anecdotes and cost does not come into the discussion, unless a treatment is simply unavailable.
Noah, the implication of your argument is that solely by virtue of being autistic, a person isn't fully capable of making their own medical decisions.
Incidentally, that was a large portion of what the actual legal case was about.
https://www.canlii.org/en/ab/abkb/doc/2024/2024abkb174/2024abkb174.html
Its always better to read the actual decision than the media articles. And much better than reading the foreign headlines which bent backwards to imply that this was a healthy minor being MAiDed for being autistic.
Thank you for the link. I agree with your advice about reading the source material. I maybe wrong (I often am), but the legal case seems to reinforce Noah's argument: MV was allowed to undergo assisted death because she chose to. MV did not present any medical grounds for why she wanted MAID and refused to rebut the medical evidence from her parents that her only established condition was Autism (and ADHD). The judge decided her decision-making rights and the fact that 2 MDs authorised it was sufficient. So to stoke the moral panic - it seems this is an example where creating a social pressure to die if you are unhappy (or inconvenient to society) and a financial incentive to the medical establishment will result in people dying 'before their time'.
And who is "qualified" to decide if I should have the right to make that decision? You insist this isn't a slippery slope argument but it is just that. There is, for example, a difference between a depressed teenager and a depressed 80 yo who has lost both a spouse and children. You may think that 80 yo isn't capable of making that decision, but what gives you or the govt that right? Is abuse possible? Yes. But I don't want my choices curtailed because of an unquantifiable but probably very small likelihood of abuse.
Yes, choice should be curtailed. You can spend your time on earth helping others if you are so personally miserable you have nothing to live for. It sounds harsh but it’s the truth- suicide is an irreversible choice and not a victimless act.
Should a depressed 19-year-old be treated the same way as a depressed 80-year-old in this regard?
Yes, the doctor should say no in both cases, assuming the depression is the only serious medical issue they are facing.
If the depressed 80 year old wants to commit suicide, there's nothing stopping them.
The medical establishment doesn't need to have a say in it.
"The question is whether doctors should recommend death to people who aren't qualified to decide whether death is a good idea"
This is NOT the question. No one, least of all doctors, want to 'recommend death.' MAID scrupulously screens applicants to ensure they are acting of their own volition. The Dutch system, which should also be included in the models being used, reviews the process after every death.
Nor is anyone suggesting 'insurance should be able to deny coverage for alternative treatments.'
The Canadian, and much longer running Dutch, examples show that this option is used by a small number (4% in both countries, interestingly), of relatively high-income educated types.
The goal is to drive policies in parallel, manage a humane end-of-live hospice network and home care system (probably for the vast majority - 96%), AND offer assisted dying as an option to those who ask for it.
More research on all the countries that offer it and their different approaches is here:
https://www.forbes.com/sites/avivahwittenbergcox/2022/10/22/a-designed-death--where--when-the-world-allows-it/?sh=627a3e177b3d
“No one, least of all doctors, want to ‘recommend death.’”
Then it should be prohibited under the policy! But it’s not, and in fact it does happen.
I enjoyed your article
4% of what? People or deaths?
I'm amused that you think Forbes is publishing pieces without thinking about the profit margins of their audience.
Also the authors of the article starts by commending the policy because their mother recently chose euthanasia.
Their 97 year old mother with a spinal cord injury.
I'm sorry but there's a world of difference between a 97 year old and a 61 year old with recent hearing loss.
Given that I'm the author of the FORBES piece, and that in my column there I can publish pretty well what I want, I'd suggest profit margins aren't the motivating factor here.
And that a 61-year old with hearing loss almost certainly wouldn't pass the review by the 2 doctors necessary to access Canada's MAID system.
It’s kind of embarrassing that you wrote a column about the topic without being aware of a prominent case like this, especially since Noah discussed it in his article! “Almost certainly” indeed! https://apnews.com/article/covid-science-health-toronto-7c631558a457188d2bd2b5cfd360a867
Asking the government to grant you the opportunity to kill yourself, and the resources to do it is not a matter of individual freedom. If anything, it’s the opposite- a sort of eugenics and definitely anti human policy.
Suicide IS the wrong choice in like 99.999999 percent of cases. In the others, you are the Iron Giant and sacrificing yourself to save the world. There are some people who are terminally ill and elderly and that is one thing worth debating, if you are physically healthy and / or have a treatable condition you should not Jill yourself, period end of discussion. Even if you think you have nothing to live for there are others who want you alive and you should stay alive for them.
What about crazy people threatening others on the bus?
They should be treated in a mental hospital / ward , not murdered by the state
I think your solution is more cruel, and in any case there are no beds
Michael Moss writes: " insurance, which essentially is not part of the Canadian health system" I myself live in the most populous province of
Canada, Ontario; and through my taxes I pay into something called the Ontario Health Insurance Plan. Of course it is insurance. It's very name says it is insurance. Plus there are many health conditions and expenses which the tax-funded OHIP does not cover, and for which people take out private insurance as well. Plus many well-to-do Canadians take out additional private insurance so that they can get treated in the US when the OHIP bureaucrats say that this that or the other thing is not covered. I strongly strongly resent the ill-informed contention that somehow Canadians benefit from a universal all-inclusive health care system, from cradle to grave that is even as generous as such programmes as the American Medicare system. And yes, it is certainly the case that the bureaucrats who administer the Ontario Health Insurance Plan take into consideration what might be called "cost effectiveness" in deciding which medical procedures should be covered and which not. Whether this involves refusing to fund expensive care on the grounds that the patient may be expected to die soon, I do not know.
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.
Sadly, this article sums up what I was just saying this to my mother the other day as we talked about what will happen to the increasing hordes of childless adults when they reach their senior years. "They're going to tell us to kill ourselves. And most people will be depressed enough to do it." :/
this has nothing to do with childlessness.
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".
Triage is happening, regardless of how much we might want to ignore it. In the US, it just isn't being done in an organized, rational manner. A few years ago, a friend's 94-year-old mother fell and broke her hip while being given a shower in a care facility. She had been bed-ridden or in a wheelchair for at least a decade. A doctor saw an "opportunity" with her injury and recommended a Medicare-reimbursed $250,000 platinum mesh repair procedure that produced no change in her capabilities at all. She died less than a year later.
Yeah what 94 year old can heal from surgery?
I actually think Noah’s last suggestion--that healthcare providers should be prohibited from suggesting MAID unless the patient brings it up first--would more or less solve the problem. "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" is always going to feel linked to the patient, whether it is or not. Just say the first part, and the patient can draw their own conclusion about whether or not they want to die as a result. This risks missing some patients who don’t know about MAID or think they wouldn’t be eligible, but that can be partially solved with a general education campaign and imo is far better than the alternative where people may be coerced. Euthanasia should be available to those who really want it, and those people will suggest it themselves. There’s no need to expand it to those who only kind of want it.
Exactly. In the UK, many (expensive) treatments are already being denied on a routine basis. NICE evaluates all taxpayer funded treatments based on cost and financial impact.
Even without assisted dying as an option, plenty of people are denied free treatment. Their alternative? Less effective treatments, or higher chance / quicker death.
Assisted dying just adds an additional option for patients, when a treatment is not possible or denied based on cost/benefit to the country.
But I don’t think you’re seeing Noah’s point that when this “additional option for patients” saves the state money, then it is incentivized to expand its use, and the actual treatments become harder to justify when a cheaper option (death) is available.
This argument arguably proves too much, though, because presumably the cheapest option is just "don't provide any healthcare, period." Doing nothing will always be cheaper than doing something. The BATNA to both providing expensive treatment *and* to euthanasia is "do nothing."
Put another way: if the state were really concerned about saving on healthcare costs, the cheapest option would be "don't provide state-sponsored healthcare" or "don't provide state-sponsored healthcare to anyone over 65." The fact that there's non-zero public care provision is the result of a political determination that it's important to provide such care, not some kind of law of nature. So if a political determination is the only reason that more-than-zero healthcare for old people exists despite the fact that it's more or less negative EV in and of itself, why are we concerned about the diminution of that political will in particular circumstances to save cash? If saving cash were the primary determinant of system structure and expenditures there wouldn't *be* a public healthcare system for retirees in the first place.
Well, I think it's similar to why (say) authoritarian states have kangaroo courts. Why bother with the pretense, why not just deal with accused people extrajudicially? Because of a political determination that some pretense of process is required for legitimacy. Euthanasia is more costly and complicated than just throwing people in the street, but it has much more legitimacy and political palatability. So when the medical establishment is given access to it, they get access to a way to save costs in ways the public will perceive as humane rather than cruel. This provides an incentive to find more and more use cases for euthanasia. That doesn't mean euthanasia shouldn't be used at all, but it does mean we should impose strict safeguards to guard against that tempting "mission creep."
I also note that you're talking exclusively about the elderly and retired, but MAID is not just available for them, and a large part of the controversy involves cases in which its use is expanded to people who may have many years of high-QALY life remaining to them.
Incrementalism works where Manicheism doesn’t.
Your argument needs clarification. Not treating or delaying timely treatment of many or even most forms of early-onset injury and infection can result in vastly more expensive intervention(s) later. Penny-wise, pound-foolish. A stitch in time saves nine, etc. It's for this reason that even many insurance companies encourage some degree of preventative care.
Denying or delaying care for patients whose condition has "stabilized", is another matter entirely. Especially where further care for minimal or no gains is extremely expensive. A complex spinal surgery, for example, can cost roughly $250k from soup to nuts in total cost; and yet the odds of that patient needing a subsequent surgery are roughly 50%. These are the sort of patients that industry would love to disappear.
The "industry" here is the taxpayer given that Noah is addressing socialized medicine vs. euthanasia in Canada -- if they were profit-motivated they just wouldn't offer the care in the first place.
I agree that private insurers face a more perverse set of incentives (as insurers always do in every industry. The goal is to take premiums, not pay out claims), although if we're in a situation where we're talking about "further care for minimal or no gains" maybe we....shouldn't be doing that further care?
My professional experience was in managing mostly chronic inflammatory pain, where more often than not 'piling on' early with lots of resources in a multi-modal approach could more often than not stop or greatly diminish a subsequent cascade into secondary and tertiary pain patterns. A stitch in time really can save nine.
State-managed care systems like CA's Worker's Comp system by necessity try to contain health care costs that are outpacing inflation in order to remain solvent. They do this by trying to apply only 'best practices' up to and until the patient ceases to improve. A medical application of the law of diminishing returns. Then it all goes into a gray zone, where the patient has to self-advocate for further care. Determining what will or will not help these patients is truly the frontier of medical practice.
The problem is where subcontracted private insurance "specialists" are brought in to help "manage" patient care, as they already do in private PPO's/HMO's. My overwhelming impression was that they would deny any and all care if they could; not just when a patient reaches the stationary phase.
I think if many health providers are pushing terminal patients to kill themselves rather than, say, putting them in hospice care, then we have far deeper problems with how such health care providers are trained and how they understand their role in society than how much they respond to financial incentives.
I think they have to swear some oath or something, I once heard.
How is it “very different”? Sounds exactly the same to this untrained ear…
The question is whether the availability of MAID did or didn't influence Canada's decision that the cost of the chemotherapy wasn't justifiable. It didn't sound to me as if it did, so it's hard to tell whether that case raises a valid concern.
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.
Not sure it's a problem with _American_ health care in particular: more likely it's a global shortage of doctors because so many retired early after suffering burnout during the Covid pandemic.
In fact I'd say the US is probably doing better with doctor availability than European countries (albeit at the cost of health care becoming increasingly unaffordable) as it wins the global bidding war for medical staff.
I only wish the US was winning "the global bidding war for medical staff." Rural areas are being depleted of any sort of available medical professionals or even facilities. The Reagan era move to glorify "unearned income" over earned income has siphoned at least three generations of our best and brightest into useless financial manipulations, leaving the country short of doctors, scientists, engineers, teachers, and other critical professionals. Vilifying government experts and others who have dedicated their careers and lives to science and analysis hasn't done us any favors, either.
I guess I'm looking at things more from my UK perspective: the NHS has long depended on third-world immigrants to staff it because such a large fraction of Britons who qualify as medical doctors chase after higher salaries in the United States or Australia.
This seems a bit problematic, "to go on to the Internet to get a broader picture of the options that exist." The Internet is not a place one should be spending time researching "alternatives" to doctor-recommended treatment, namely because there's little-to-no data on the efficacy of those treatments and in reality - almost none of them work. My husband is a medical oncologist and the agonies he's experienced from patients determined to do everything to avoid his recommendations who then head to quack clinics in Germany vs. undergoing specific, targeted therapies for treatable cancers are legion. Any patient can and should be an active partner in their treatment plan for whatever illness they're experiencing. But medicine shouldn't be a buffet-style restaurant where one picks and chooses from a plethora of options when many of those on offer are akin to snake oil or worse.
My top sites for web research are the Mayo Clinic website, Johns Hopkins website, the Cleveland Clinic website, and WebMd.
I am generally quite enthusiastic about mainstream medicine. The number one problem is that the doctors I encounter don't seem to be aware of all the treatment possibilities that exist within mainstream medicine.
For example, one very important part of my daily pill regimen is a treatment that has been standard for 60 years in Germany (very mainstream there) but is hardly known in the United States. I brought it up with one of my best doctors and asked why he did not recommend it. He told me that he used to, but it didn't work for everyone.
I am much more careful in evaluating “alternative” treatments, but I have found at least one that dramatically reduced my cholesterol levels consistently for over 10 years now, from 200 to an average of about 140.
Perfect. This seems like an area where AI may be provide a very good assist.
Generally speaking, I'm not a fan of Bing, but they have an AI program called Copilot that is very good as a starting point for Internet research focused on mainstream medicine. Copilot leaves Chat GPT in the dust. The button is located in the upper right-hand corner of the Edge page.
Aren’t they the same thing?
No. Chat GPT and Copilot are completely independent of each other. They are the same type of program but have completely different origins. Mercedes and BMW's are both cars, but they are not the same.
Not necessarily. "Garbage in, garbage out," is far more likely for anything but the simplest diagnoses. Especially if there's a profit motive that encourages/discourages either specific treatments or denial of care.
A far more likely scenario is that that AI will begin to replace health insurance adjustors and care managers, who are already reflexively likely to deny and/or delay care.
Physicians do not recommend treatments based on their cost.
"Medical Necessity" is where the rubber meets the road. In clinical practice this can be a very fluid concept, especially in acute conditions. Insurance companies now track physicians who prescribe too many treatments or diagnostic procedures that the industry considers unnecessary or overly expensive compared to alternatives, and will drop them from their provider rolls as a consequence. In CA this appears to be a growing trend.
This is a source of extreme professional stress for medical professionals. In California, at least. Talk to any MD or nurse who works in a hospital or managed care setting if you don't believe me.
"He told me that he used to, but it didn't work for everyone."
Was your doctor effectively saying here that he won't prescribe this medicine because he fears being sued if it doesn't work?
Not at all. He is a wonderful brave man.
I just think the batting average for this medication was too low for him to keep recommending it.
But it's been a lifesaver for me—hard to imagine being able to get to sleep without it. The pain became worst the minute I laid down--don't know why.
PS I am in total agreement with you that most alternative therapies have not been researched to the point that would make me happy. And I also agree that cancer patients are peculiarly desperate and willing to grasp at any shred of hope.
Having been an Alternative Medicine provider in CA for 25 years, my experiences largely validate your conclusions. Modern medicine in today's America is mainly a huge turf-fight for $$$ between the three dominant stakeholders: Big Pharma, Health Insurers, and the AMA & Nurses Unions.
Many quite effective Alternative Medicine treatments and therapies are quite frequently ignored or overlooked in favor of the often far more expensive conventional methods. And this includes cancer.
A basic problem is that natural occurring materials cannot be patented and become the source of great profits. Accordingly, they don't get researched. My total cholesterol has been dramatically and reliably reduced for the last 10 years by a combination of berberine and cinnamon extract. I've gone from 200 to 140.
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).
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.
Hi Kathleen,
Your comment telling the story of Charlie is an important contribution to this issue. To watch someone close to you suffer with minimal or no hope of improvement is painful when a release from suffering is not legal. As Noah wrote, it seems as if euthanasia is likely to continue to spread so regulating it so that individuals are not stripped of agency by the medical profession is very important.
To summarize, the wider availability of euthanasia will put tremendous pressure on family members who are torn in their feelings about loved ones.
I downplayed the fact that Charlie could be very scary when he flew into a rage in his last two years. 99% of the time he confined himself to destroying inanimate objects but that doesn't make a vulnerable woman feel much better!
I did have an order of protection against him at one point. It was clear that a physical separation was the best solution. But I still always loved his good side, which was quite extraordinary. I agreed on this statement with someone who knew him well: "He was much better than average and much worse than average—the only thing he wasn't was average.”
Six years ago my wife was suffering the last stages of terminal lung cancer. The pain had become so unbearable that we were exploring ending her life via California's death with dignity law. It was at that moment that a random California Superior Court judge put a stay on the entire law for the most incredibly specious reasons (saying the law couldn't be passed during a special legislative session).
I cannot tell you how devastating that decision was for us and how I believe it contributed to a spiraling down for her, followed by an ugly and horrific death two weeks later, a memory that curses me to this day.
Clearly, we need to police death with dignity laws along the lines Noah proposes. But we have to stand fast and hard against actors who would use horror stories like he relates to take away something so often vitally needed. This kind of law, properly administered, is humane and a sign of a wise and caring society.
I'm so sorry to hear about what you and your wife went through. We should strive for a balance. Families should be protected from both doctors and courts.
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.
Also, of course medical aid in dying is not legal everywhere in the US—only in a handful of mostly progressive states and DC.
"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.
The alternative explanation is that US cancers are diagnosed earlier and more frequently, which would raise life expectancy after detection even if actual outcomes were unchanged
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.
Except they DO bring it up, and patients are too fearful of repercussions to report it. I realize this is anecdotal, but I have had three close friends with treatable but chronic conditions bc offered MAID, even though they were trying to get stable / get adequate care. One was even told they were a burden on the system. By the attending.
I’m all for dignity in dying, but it needs to have safeguards so it is not used as a bludgeon for people who want to live.
In this regard rules are only as good as their enforcement. We should feel more comfortable filing a complaint against a doctor. I know one person that did and it took some time and frustration, it wasn't over MAID.
Being told you are a burden is being a highly paid @#$ but is not the same as suggesting MAID.
Perhaps you haven't been put in the position where there's a limited amount of specialists for your condition. In this case, filing a complaint for this issue would only cause more challenges to care — care that is already sorely lacking.
Perhaps my comment was insufficiently clear: they were told they were a burden AND that they ought to consider MAID.
If they were specifically told to consider MAID then the doctor should be diciplined. What should be and what is are often not the same I'm afraid.
Indeed, it isn't often the same — which is the point Noah made in this piece, and what I was reiterating in the comments. Disciplinary reports are not safeguards by any means; they can help in some cases, but in the experience of the vulnerable patients I hear from often, they only further penalize the people seeking care. More is needed.
It is indeed a system that needs improvement. Somethign this seriouse and important should never seem settled. My wife's a nurse and much more knowlegable on this but I'm pretty sure the doctor or doctors that have suggested MAID are not likely the same doctors that will actually carry it out. It also takes more than one doctor to sign off.
"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."
Generally palliative care should be offered much earlier than it normally is. There was an important New England Journal of Medicine article years ago showing survival was longer in the patients given palliative care along with their standard care for colon cancer vs. just standard care.
A lot of this concerns the pendulum-effect attitude towards opiates here in the US, where we have gone through cycles of over- and then under-prescribing opiate analgesics.
The role of the insurance industry in directly and indirectly "encouraging" MD's to deny Rx. care is also a substantial and worsening trend.
“Canadian doctors are not allowed to mention or otherwise bring up MAID as an option.”
Where do you see that? This article (https://apnews.com/article/covid-science-health-toronto-7c631558a457188d2bd2b5cfd360a867) says the opposite: “The Australian state of Victoria forbids doctors from raising euthanasia with patients. There are no such restrictions in Canada. The association of Canadian health professionals who provide euthanasia tells physicians and nurses to inform patients if they might qualify to be killed, as one of their possible “clinical care options.””
My wife's a nurse here in Canada and this is her responce and a few links.
"Physicians need to tell patients that their condition can no longer be treated or treatment can cause harm versus benefit and a palliative approach is more appropriate. Patient can continue to request futile treatment and receive it until their capacity is impaired. It is hard for people to hear that there isn't much can be done for the condition or risk for harm is too high. "
So if you have a treatable condition they shoudl not be bringing it up. If you condition is not treatable they should bring it up I supose.
"qualified to be killed" suggests some bias in your opinion around this.
https://www.ontario.ca/page/medical-assistance-dying-and-end-life-decisions-support-medical-professionals
https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html#:~:text=As%20of%20March%2017%2C%202021,the%20result%20of%20external%20pressure
Thanks for sharing these. However, I don't see anything in your wife's statement or in either of the links (granted I did not read them thoroughly since they're both quite long) that says doctors are not allowed to raise or suggest the topic. One of the links did say the decision to die cannot be the result of external pressure, but as far as I can tell that does not prohibit doctors from mentioning it, as you said. If I'm missing something, please let me know.
"Qualified to be killed" is part of the quote from the AP article, not my own words. The article is clearly skeptical of assisted suicide for people with non-terminal illness, and so am I; you could call that a "bias," but in that case anyone who holds an opinion is biased. Lots of people in these comments spoke of how they wished they had assisted suicide available to relieve suffering of ill relatives; is that a "bias" that they should strive to eliminate or else not comment? But in any case I'm not sure if I even see what's objectionable about "qualify to be killed." If someone is administered fatal drugs, are they not killed? What would be a more acceptable term?
I think I conceeded that if you have a non treatable ilness the doctor should be telling you your options. A little different than the fear mongering that doctors are looking for people to kill. Noapinion's article could have done a better job of spelling out the process.
If someone is killed it implies some blame doesn't it, the doctor killed him is a better attention grabbing headline than a doctor helped someone end theri suffereing from a terminal illness.
I hadn't understood that you were withdrawing the claim "Canadian doctors are not allowed to mention or otherwise bring up MAID as an option." Sorry if I misunderstood.
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.
Excellent observation—shouldn’t be overlooked.
“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,
FWIW, I’m an atheist and I’m happy you’re here. It’s good to be challenged by people with different opinions and worldviews, as long as everyone argues in good faith, rather than be stuck in an echo chamber. I hope you’ll stick around. 😊
"I used to think this about Paul Krugman until he became, well, a bit rabid."
"DNC-NYT Ass Clown" would also be accepted for full credit.
He was already ridiculous before 2016, but like so many others, Trump broke his mind.
Lol! I was trying to be a bit more winsome but the recovering Marine in me finds your comment, probably perversely, hilarious.
He's still usually correct about things. :/
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.
Also, I just went back and read that Matthew Parris quote, yuck! Embarrassed by my country's 'intellectual' class spouting nonsense in the Op-Ed pages once again...
The role of the insurance industry in "encouraging" physicians to deny care in the US is not being addressed in this article. Here in CA, medical doctors can and are dropped from reimbursement from specific plans if they are deemed to "overprescribe" treatment. For doctors not practicing in boutique cash-only practices this can be devastating.
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"
It feels terrible to talk about fiscal costs, but it's a reality just as much as the human situation. I am grappling with this right now, having just moved my mother into memory care due to rapid progression of her dementia. Until you've dealt with it, you can't fathom how ugly and expensive it is.
My mom's memory care isn't covered by insurance and costs approximately $96K per year. She is currently on her second stint in geriatric psych to try to find a medication combo that will enable her to stay at memory care, as the dementia is causing a lot of fear/agitation and inappropriate behaviors to staff and other residents. If we can't stabilize her, our next alternative is either to keep her in geri psych until she dies, which is costing Medicare thousands of dollars per week, or possibly to sedate her to the point where she's manageable in the skilled nursing facility, which is $180K per year. The only other thing to do would be for one of us kids to quit our jobs, move her into our home, and devote ourselves to trying to provide 24/7 care -- and I do mean 24/7, she wanders all night, falls constantly and is a danger to herself and others.
I love my mother and will be gutted when she dies. I also wish every day that she will not wake up so that this will be over for her. She would not have wanted to live like this, but it's how she will likely continue to live for the next year or two of her life. She will die in indignity and quite possibly after undergoing a lot of pain and fear. And I don't know how in the world we'd be paying for it if our family weren't well off. It's all very well to say that finances shouldn't matter, but the enormous costs have to be covered for somehow, out of our own pockets, the government's, or our labor.
If she had anticipated getting to this point, and if MAID had been available to her, she would have chosen it in a heartbeat. If I'm diagnosed with Alzheimers one day, I know I will do it as soon as possible while I still have the capacity to make the choice. I won't put the emotional, logistical, or financial burdens that I am currently carrying onto my children.