Monday, August 13, 2012

Death and choices

Two apparently unrelated stories in the NY Times both raise the issue of what choices about the end of life are and should be available, for the terminally ill, and for others.  One concerns the experience of Oregon and Washington* with physician assisted death for terminally ill patients, the other concerns the sale of life insurance contracts to investors.  Both involve transactions that used to be, and still often are, regarded as repugnant, in one case between doctors and patients, and in the other between patients (or simply the elderly) and anonymous investors.

Assisted suicide for the terminally ill has long been controversial, and the Washington law insists that prescription drugs be "self administered" which can be a problem when movement and swallowing become hard.  On the insurance side, "viatical settlements" are often regarded as repugnant because the investors win when you die, as opposed to life insurance companies which make their money while you live. But, of course, insurance companies also offer annuities, in which they win when you lose... (See my 2009 post on "Death Pools".)

Here are some quick summary quotes from the two stories...

A Surprise Reflection of Who Picks Assisted Suicide

"Washington followed Oregon in allowing terminally ill patients to get a prescription for drugs that will hasten death. Critics of such laws feared that poor people would be pressured to kill themselves because they or their families could not afford end-of-life care. But the demographics of patients who have gotten the prescriptions are surprisingly different than expected, according to data collected by Oregon and Washington through 2011.
"While preparing advance medical directives and choosing hospice and palliative care over aggressive treatment have become mainstream options, physician-assisted dying remains taboo for many people. Voters in Massachusetts will consider a ballot initiative in November on a law nearly identical to those in the Pacific Northwest, but high-profile legalization efforts have failed in California, Hawaii and Maine.

"Oregon put its Death With Dignity Act in place in 1997, and Washington’s law went into effect in 2009. Some officials worried that thousands of people would migrate to both states for the drugs.

“There was a lot of fear that the elderly would be lined up in their R.V.’s at the Oregon border,” said Barbara Glidewell, an assistant professor at Oregon Health and Science University.

"That has not happened, although the number of people who have taken advantage of the law has risen over time. In the first years, Oregon residents who died using drugs they received under the law accounted for one in 1,000 deaths. The number is now roughly one in 500 deaths. At least 596 Oregonians have died that way since 1997. In Washington, 157 such deaths have been reported, roughly one in 1,000.

"n Oregon, the number of men and women who have died that way is roughly equal, and their median age is 71. Eighty-one percent have had cancer, and 7 percent A.L.S., which is also known as Lou Gehrig’s disease. The rest have had a variety of illnesses, including lung and heart disease. The statistics are similar in Washington.

Are You Worth More Dead Than Alive?
"Fiedler, who owns a firm called Innovative Settlements, knew that a life-insurance policy is an asset that can be resold to a friend or stranger just as a car, boat or house can. In a transaction known as a viatical settlement (for terminally ill patients) or a life settlement (for everyone else), the person selling his insurance gets an immediate cash payment. The buyer, in exchange, is named as the beneficiary and pays the premiums until the insured person dies. Life no longer afforded Robles a traditional way to make money, but to the right investor, Fiedler advised, his imminent death was worth a great deal.
"Betting on when somebody will die seems so creepy that it’s hard to believe the practice is legal. Sure, people pay good money to buy life-insurance policies, so perhaps that should confer the right to sell them as well. But the freedoms of ownership are not unlimited, especially when it comes to anything related to life and limb. Possession of and control over what happens to your own body is a fundamental human right. Nonetheless, that hasn’t stopped cultures from banning prostitution, organ sales or for-profit surrogate parenthood. The justification for such infringements upon bodily sovereignty is that people should be protected from financial incentives to harm themselves, and you could argue that a life settlement creates just such an incentive."


*The Washington Death with Dignity Act, Initiative 1000, codified as RCW 70.245, passed on November 4, 2008 and went into effect on March 5, 2009.
This act allows terminally ill adults seeking to end their life to request lethal doses of medication from medical and osteopathic physicians. These terminally ill patients must be Washington residents who have less than six months to live.


diƤtplan said...

very good post

dWj said...

I've wished for a while that I could buy life insurance from my health insurance company, just to better align incentives.