Special Article

What Are the Potential Cost Savings from Legalizing Md-Assisted Suicide?

Listing of authors.
  • Ezekiel J. Emanuel, Chiliad.D., Ph.D.,
  • and Margaret P. Battin, Ph.D.

Introduction

In the Washington five. Glucksberg and Vacco v. Quill decisions rejecting a constitutional right to physician-assisted suicide, the Supreme Court immune each state to make up one's mind whether to legalize the intervention.one In state legislatures rather than courtrooms, factual claims almost the probable extent and implications of permitting physician-assisted suicide presume a preeminent role in the debate about legalization.2 Particularly sensitive in these discussions will be the issue of the potential cost savings from legalizing dr.-assisted suicide, and how the savings might influence determination making by health intendance institutions, physicians, families, and terminally ill patients.3-6

Although we exercise not agree with each other about the ethics or optimal social policy regarding dr.-assisted suicide and euthanasia, we exercise agree that the claims of cost savings distort the debate. Inside the limits of bachelor data, nosotros offer an assessment of the potential cost savings from legalizing physician-assisted suicide, demonstrating that the savings can be predicted to be very small — less than 0.i percent of both total health care spending in the United States and an individual managed-care plan's budget.

Speculating about Price Savings from Physician-Assisted Suicide

There is a widespread perception that the United States spends an excessive amount on high-technology health care for dying patients.vii-20 Many commentators note that 27 to 30 percent of the Medicare budget is spent on the v percent of Medicare patients who die each year.21 They also note that the expenditures increase exponentially as decease approaches, so that the final calendar month of life accounts for 30 to 40 percent of the medical care expenditures in the terminal year of life. To many, savings from reduced use of expensive technological interventions at the end of life are both necessary and desirable.11,12,18,19

Many have linked the effort to reduce the high price of death with the legalization of physician-assisted suicide. One commentator observed: "Managed care and managed decease [through physician-assisted suicide] are less expensive than fee-for-service care and extended survival. Less expensive is better."22 Some of the amicus curiae briefs submitted to the Supreme Courtroom expressed the same logic: "Decreasing availability and increasing expense in health care and the uncertain affect of managed care may intensify force per unit area to choose dr.-assisted suicide"23 and "the cost effectiveness of hastened death is equally undeniable as gravity. The earlier a patient dies, the less costly is his or her intendance."24 Indeed, the Supreme Court noted the potential for cost-saving motives to influence the legalization and use of medico-assisted suicide, speculating that "if physician-assisted suicide were permitted, many might resort to it to spare their families the substantial financial burden of end-of-life wellness care costs."i

Factors Determining Savings from Physician-Assisted Suicide

Computing the likely toll savings from legalizing physician-assisted suicide is based on three factors: (1) the number of patients who might commit suicide with the aid of a physician if it is legalized; (two) the proportion of medical costs that might be saved by the use of physician-assisted suicide, which is related to the amount of fourth dimension that a patient's life might exist shortened; and (3) the full toll of medical care for patients who die.

Each of these factors is uncertain. Although available data point that physicians in the U.s. currently provide euthanasia and aid with suicide to some patients,25,26 information technology is incommunicable to determine how many additional Americans would die equally a outcome of physician-assisted suicide if it were legalized. The savings from legalization would depend on the additional number of physician-assisted suicides across the electric current number. Since predictions almost any patient's precise date of death are inherently uncertain, it is impossible to determine how much life would be forgone. Finally, only limited data are bachelor on the costs of care near the end of life in the United States.15,16,21 However, by combining data on physician-assisted suicide and euthanasia in holland, where these interventions are openly performed27,28 and have been studied,29-31 and available U.S. data on costs at the end of life, we tin can estimate the cost savings that would be realized in the United States if md-assisted suicide were legalized. Although such an guess is very rough, sensitivity assay tin can minimize the effect of the uncertainty by providing the range of savings under reasonable conditions.

The Number of Patients Who Might Choose Physician-Assisted Suicide

In kingdom of the netherlands, approximately 3100 cases of euthanasia and 550 cases of physician-assisted suicide occur annually, representing two.3 per centum and 0.four percent, respectively, of all deaths.31 (In that location are an additional one thousand cases [0.7 percent] in which euthanasia is performed without the patients' explicit, current consent.31 Such cases are neither sanctioned in the Netherlands nor permitted by the current proposals for legalization of md-assisted suicide in the United states.) Most 80 percentage of deaths by doctor-assisted suicide or euthanasia in holland involve patients with cancer, representing 6 per centum of all deaths from cancer.30,31 Extrapolating the Dutch rates to the United States suggests that approximately 62,000 Americans (two.7 percent of the 2.iii 1000000 who dice in the United states each year) might cull physician-assisted suicide if it were legalized and carried out with the explicit, current consent of the patients. Patients with cancer are also likely to be the principal users of doctor-assisted suicide in the United States.25,26

Proportion of Life Shortened by Physician-Assisted Suicide

Although predicting the exact date on which an individual patient will die is impossible, physicians are fairly accurate in predicting the time of death on a population basis, especially for patients who die of cancer.16,32 Dutch physicians guess that 17 percent of patients receiving euthanasia or a doc's assistance with suicide at the patients' explicit asking had their lives shortened by less than one day, 42 per centum by i mean solar day to i calendar week, 32 percent by more than than 1 week to four weeks, and nine percent by more than one month.thirty,31 Thus, more than 90 percent of Dutch patients who died as a result of physician-assisted suicide or euthanasia at their own explicit asking had their lives shortened by 4 weeks or less, with an boilerplate life reduction of less than three.three weeks.

The Costs of Medical Care for Dying Patients

Determining the costs of medical care at the terminate of life and how much would be saved by legalizing physician-assisted suicide is made difficult by several problems with the available data. It is speculative to assume that patients who might commit dr.-assisted suicide would swallow resources at a rate like to that of patients who do not; such patients may be considerably different from average decedents in terms of health status, psychology, and sociodemographic characteristics, using more than (or fewer) wellness intendance resources at the end of life.25 Also, the all-time data available in the Usa on the price of medical care at the stop of life come from Medicare, which provides mainly acute care for the elderly and disabled.33,34 Studies accept come to various conclusions about whether these Medicare data tin be extrapolated to decedents under 65 years old.35-38 According to contempo Medicare data, for a beneficiary who dies of cancer after receiving conventional care, $thirty,397 (in 1995 dollars) is spent on medical care in the final yr of life.39,40 Fully 33 percent of the final year's costs ($10,118 in 1995 dollars) are spent in the concluding month of life, and 48 percentage ($14,507 in 1995 dollars) in the last two months of life. (The available information exercise not define costs in whatever smaller increments of fourth dimension.)

Estimated Toll Savings from Legalizing Physician-Assisted Suicide

Table 1. Tabular array 1. Estimated Toll Savings from the Use of Physician-Assisted Suicide by Patients with Cancer Who Receive Conventional Intendance (in 1995 Dollars).

Assuming that (1) 2.7 percent of patients who die each yr (62,000 Americans) would choose doctor-assisted suicide, (2) these patients would forgo an average of 4 weeks of life, and (iii) the medical costs in the final month of life for each patient who dies are $10,118 (in 1995 dollars), we estimate that legalizing doc-assisted suicide and euthanasia would save approximately $627 million in 1995 dollars (Table one). This corporeality is less than 0.07 percent of total U.S. wellness care expenditures.

Overestimation and Underestimation of Cost Savings

This calculation may produce a considerable overestimate of savings. In six ways, the adding is biased to inflate the savings. First, we causeless that U.S. physicians would fulfill their patients' requests at the same rate that Dutch physicians practise. Yet in the Netherlands 53 pct of physicians accept provided assistance with suicide or administered euthanasia, and just 4 percent state that they would neither practice so nor refer a patient to another medico who would.29,31 In contrast, surveys of American physicians advise that a substantial majority would refuse to provide assistance with suicide, even if information technology were legalized.25,26,41,42 Unless legalization greatly contradistinct physicians' practices, having fewer American physicians willing to assist in suicide would probably mean that fewer American patients would receive such assistance.

Second, we estimated the average amount of life forgone by patients who die as a result of physician-assisted suicide at iv weeks, which may exist besides loftier. The average time forgone by Dutch patients who receive euthanasia with their consent is less than 3.iii weeks, with 59 percentage forgoing 1 week of life or less. Clearly, the more life forgone, the greater the projected savings. In add-on, Dutch physicians estimated that 8 percent of the patients who died every bit a effect of physician-assisted suicide or euthanasia would accept lived longer than vi months29,thirty; such patients are not "terminally ill," as divers past Oregon's law governing md-assisted suicide and most American proposals for legalization, and thus would non be permitted to receive a doctor's assistance with suicide in the United States.

Third, we calculated the savings by using the costs of care for patients with cancer and generalized these costs to all patients who might choose md-assisted suicide. Nevertheless because of the intensity of their care, patients with cancer accept some of the highest costs at the end of life.33,34 Patients with other diseases, such as multiple sclerosis or amyotrophic lateral sclerosis, who might cull physician-assisted suicide are likely to have lower overall medical costs and thus are likely to represent less money saved.

Fourth, when computing the costs at the end of life, we used the costs for patients receiving conventional care for their cancers. The medical expenditures for patients who receive hospice care during the last two months of life are substantially lower than those for patients receiving conventional care ($9,548 vs. $14,507 in 1995 dollars), suggesting that the savings from physician-assisted suicide would be less for patients receiving hospice care.31,40-42

Fifth, recent surveys bespeak that some terminally ill patients in the Us have died equally a result of doc-assisted suicide or euthanasia, although it is impossible to determine precisely how many.25,26,43 The cost savings realized from these cases in which death was hastened are already deemed for in the health care system and are double-counted in our calculation.

Finally, nosotros take not included the additional costs that legalizing physician-assisted suicide would entail. Proposals for legalization include the requirement that a second physician confirm that the patient is terminally ill and understands the implications of requesting a physician's assistance with suicide. Some proposals would mandate a psychiatric evaluation of patients making such a request. Others, such as Oregon's Death with Dignity Act (Measure 16), require referral of patients for counseling if they might take depression or some other psychiatric disorder. Measure out sixteen also requires the state to assemble statistics on the use of physician-assisted suicide. In that location is likely to exist litigation, such as investigations and prosecutions of physicians who violate the safeguards. All these activities would increase the medical and legal costs, thereby reducing the net savings from md-assisted suicide.

Conversely, several considerations suggest that these calculations may underestimate the potential savings from dr.-assisted suicide. Our utilise of Medicare costs at the end of life might have caused united states of america to underestimate the total health care costs and therefore the potential savings. According to some, the average Medicare costs for care at the end of life do non accurately reflect the costs for all dying patients, especially for patients in tertiary care facilities. Likewise, Medicare Part A and Part B exercise not cover all health care costs; indeed, substantial costs, predominantly nursing domicile costs, are not included.34,forty Even so, in the Netherlands, euthanasia and dr.-assisted suicide are quite rare amidst patients in nursing homes — just 2 per centum of all cases — suggesting that the absence of nursing dwelling house costs from these calculations does non produce a large underestimate.30,31

In addition, in the The states, family members provide substantial care for dying patients, adding to the overall costs of intendance at the terminate of life.44 Because at that place are no studies that accurately quantify the fiscal costs of family unit care for dying patients, such costs are not usually computed in the assessments of wellness care costs at the end of life.xl By ending patients' lives earlier, physician-assisted suicide would reduce the costs associated with family care. There is currently no mode to quantify these savings.

Table 2. Table 2. Estimated Price Savings from the Use of Physician-Assisted Suicide by Patients with Cancer Who Receive Hospice Intendance (in 1995 Dollars).

To acknowledge the dubiousness in these estimates, Table 1 and Table 2 present analyses of the savings in various circumstances, varying the proportion of the population that might cull physician-assisted suicide, the amount of life forgone, and the expenditures for medical care at the end of life. The lower bound of savings assumes that 2.7 percent of dying Americans (62,000) might choose doc-assisted suicide, forgoing iv weeks of life and using hospice intendance at the end of life. These assumptions produce a savings of $336 million (Table 2). Conversely, the most inflated assumptions are that 7.0 per centum of dying Americans (161,000) might choose md-assisted suicide, forgoing an boilerplate of eight weeks of life at twice the average Medicare expenditures ($29,014). These assumptions produce savings of $4.67 billion.

Managed-Care Plans and Price Savings from Physician-Assisted Suicide

Although the total national savings from the legalization of physician-assisted suicide might be pocket-sized, there is concern that toll competition might still tempt managed-intendance plans to encourage the practice. Several of the amicus briefs submitted to the Supreme Court raised this specter: "Information technology is certainly plausible and peradventure fifty-fifty likely that upkeep-minded health care organisation managers and their doctor-employees would press their dying patients toward exercising [a right to receive a physician'south assistance with suicide]" and "agonized and depressed patients would elect to accept their deaths facilitated since their relievable suffering went unalleviated because of their wellness providers' financial imperatives."23,24 In the abstract this claim seems implausible, since one of the main ways managed-care plans save money is past enrolling healthier members, including healthier Medicare beneficiaries, who are less probable to be terminally ill. Withal, it may correspond to the motives of some managed-intendance executives and certainly seems to express public suspicions. How much would managed-intendance plans salve by encouraging the apply of physician-assisted suicide?

One large managed-care programme currently enrolls approximately 1.7 meg adults and has an annual upkeep of almost $4.5 billion. In 1995, approximately 13,000 of the enrolled adults died, including 3800 who died of cancer. Over the last six months of life, the hateful cost for patients enrolled in this managed-care plan who died of breast cancer was $21,329 (in 1995 dollars), with about $9,500 spent in the last month of life.45 Bold that 2.7 per centum of the patients who died would take chosen medico-assisted suicide (351 patients), forgoing an boilerplate of four weeks of life at an average savings of $nine,500, the managed-care plan's expenditures would accept been reduced by $3.3 one thousand thousand, or less than 0.08 percent of its full budget. For other managed-care plans that tend to have higher proportions of young, healthy patients with lower decease rates, the absolute and relative savings are likely to be even smaller.

Families and Cost Savings from Physician-Assisted Suicide

Although the cost savings to the U.s.a. and most managed-care plans are likely to be small, it is important to recognize that the savings to specific terminally sick patients and their families could be substantial. For many patients and their families, specially but not exclusively those without health insurance, the costs of terminal care may issue in large out-of-pocket expenses.44 Nevertheless, as compared with the average American, the terminally ill are less likely to be uninsured, since more than than two thirds of decedents are Medicare beneficiaries over 65 years of age. The poorest dying patients are likely to exist Medicaid beneficiaries. Extrapolating from the Medicare information, one can calculate that a typical uninsured patient, by dying one calendar month earlier by means of dr.-assisted suicide, might save his or her family unit $x,000 in health intendance costs, having already spent equally much equally $20,000 in that yr. Some patients using intensive medical services may incur considerably college health intendance costs. If uninsured nonhospice patients with cancer were to cull medico-assisted suicide half dozen months earlier their natural deaths — the primeval betoken permitted under current proposals — the average savings for the family unit could be $20,000. Although the overall national savings from legalizing physician-assisted suicide might exist small, for many families — peculiarly those of uninsured patients — the savings could be substantial. What savings level, if whatsoever, would motivate families to pressure patients into requesting a dr.'due south assistance with suicide is a matter of speculation but one that cannot be ignored.

Why Are the Price Savings from Physician-Assisted Suicide So Depression?

The estimated cost savings from permitting physician-assisted suicide are lower than many people wait. One reason for this disparity is the frequent overestimation of how much is spent on medical intendance at the end of life. One commentator claimed that "some 70 to 90% of our health intendance dollar is spent on the last few months of life."17 Others have suggested that the costs of intendance for dying patients business relationship for almost 30 pct of all health intendance expenditures.10 In fact, each year about x percent of expenditures for medical care involves patients who die.twoscore The less spent on patients who die, the smaller the cost savings from dr.-assisted suicide.

Another reason may be that people overestimate the number of Americans who die each yr. Less than ane pct of Americans die each yr. Of these, many would exist unable or ineligible to request a physician's help with suicide, even if it were legalized: newborns with serious birth defects, minors, victims of trauma, persons who dice all of a sudden from myocardial infarctions or strokes, and patients with dementia. More important, if Americans were to choose physician-assisted suicide at the aforementioned rate equally the Dutch choose euthanasia, only 0.027 percentage of Americans might choose physician-assisted suicide if it were legalized. Put another mode, more than 99.97 percent of Americans would continue to receive the usual health care at the usual cost. Considering doctor-assisted suicide would not affect the health intendance provided to the vast majority of Americans, it would non substantially reduce overall health care costs.

Finally, doc-assisted suicide is non an option almost people would be likely to choose much before their "natural deaths." Equally the Dutch data demonstrate, the average amount of life forgone by all patients electing euthanasia or physician-assisted suicide is less than iv weeks.30,31 Although the intendance given in the final iv weeks of life accounts for a considerable proportion of health intendance costs, it notwithstanding represents merely 33 percent of all medical expenditures during the final year of life and an even smaller fraction of lifetime wellness care expenditures.39,40 Considering the small fraction of Americans who would cull dr.-assisted suicide, the small fraction of life they would forgo, and the minor fraction of total wellness intendance expenditures associated with their care, the savings that would result from the legalization of physician-assisted suicide represent a very pocket-sized fraction of total health care expenditures.

Conclusions

Drawing on information from kingdom of the netherlands on the utilise of euthanasia and physician-assisted suicide and on available U.S. information on costs at the terminate of life, this assay explores the degree to which the legalization of physician-assisted suicide might reduce wellness care costs. The virtually reasonable estimate is a savings of $627 million, less than 0.07 percent of total wellness care expenditures. What is true on a national scale is also likely to exist reflected in the potential savings for private managed-care plans. Dr.-assisted suicide is not likely to save substantial amounts of money in absolute or relative terms, either for particular institutions or for the nation equally a whole.

Funding and Disclosures

We are indebted to Dr. Paul van der Maas, Dr. Miles Brown, Dr. Jane Weeks, David Guberman, Dr. Jay Jacobson, Dr. Jeff Botkin, Dr. David Light-green, Dr. Leslie Francis, Evelyn Kasworm, and January VanRiper for helpful ideas and criticisms of the manuscript.

Writer Affiliations

From the Center for Outcomes and Policy Research, Partitioning of Cancer Epidemiology and Control, Dana–Farber Cancer Institute, and the Division of Medical Ethics, Harvard Medical School, Boston (E.J.E.); and the Department of Philosophy, Academy of Utah, and the Partition of Medical Ethics, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City (M.P.B.).

Address reprint requests to Dr. Emanuel at the Center for Outcomes and Policy Inquiry, Division of Cancer Epidemiology and Command, Dana–Farber Cancer Constitute, 44 Binney St., Boston, MA 02115.

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