Inconsistencies with Libertarianism: A view through Healthcare Policy

March 15, 2008

Healthcare Ethics

Oregon in November 1994 passed a law allowing physician assisted suicide. In

Lee v. Oregon, the law was ruled unconstitutional, while the Ninth Circuit Court in 1997

overturned the previous ruling. An attempt in November of that year was made to repeal

the law by vote but it failed and subsequently Oregon now allows physician assisted

suicide (Snyder, 2006). Proponents of regulated suicide and those in favor of extending

palliative care view patient’s autonomy, financial resources, and societal stress, the

personal care of a patient and the long-term effects of suicide as major factors in their

stance of the issue. National Health Care policy and our public health system has been a

wedge of complication in this issue splitting the two sides quite effectively. What is of

concern is the logic behind the assisted suicide debate and advocacy groups in general.

Progressive rights can and do outstrip the ethics that support them over time.

The benefits of our healthcare system have been scattered between the upper

class, middle-class, and the poor, through a mixture of public and private insurance. The

goal of healthcare by large is to protect and enhance the well being of those who can least

effect or afford to do so themselves (Bluhm & Heineman, 2007). In essence, this is a

form of utilitarianism with the good of society outweighing the lack of treatment due to

cost. However, utilitarianism in this respect is a double-edged sword because the premise

of cost effectiveness can be used to weaken healthcare and is prominent in advocates

arguments wishing to promote adequate pain management, palliative care, and an

expansion of Hospice services.

Providing healthcare services or any time funded- re-allocation of resources from

the few to the many has been a methodology wrought with intricacy of regulation and

formula. There is the implication as Randall B. Ripley and Grace. A Franklin found that

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Healthcare Ethics

intense, powerful opposition from the few with resources will become highly organized

and will disproportionally move policy toward favoring their benefit against the masses

(Bluhm & Heineman, 2007). In essence, this can be summarized as the masses blunt

pressure of need vs. the minorities vaulting of the spear of protection. Due to the nature

of healthcare, cost conflicts, and most large policy implementations, change in America

in any one direction has been incremental. Only in a severe moments or windows of time

have health care policy direction movements been large, such as during the New Deal

and a second time during the Great Society (Bluhm & Heineman, 2007).

Those advocating assistance in suicide remark that the overarching view of

depression in suicide cases proves too much and is too broad a sweep to be useful as a

litmus test for deciding against laws regulating assisted suicide (Harber, 2000). Of the

majority of those who are depressed there is some who can decide the costs of living

against the benefits of dying from a terminal illness (Harber, 2000). Those who are

severely suffering from an illness without the ability to recover do understand the

capacity of life and that of death. Both the view that killing oneself devolves natural law

or Kantian law; one of contradiction of itself is not in itself convincing (Harber, 2000).

What remains is the high cost of living with severe, debilitating pain and death (Harber,

2000).

Corollary can be used between U.S smoking policy and U.S assisted suicide

policy. The impetus for this is because both can involve U.S Healthcare policy, personal

autonomy and wealth distribution and transfer. Distribution and transfer of healthcare

dollars or insurance coverage has been fragmented at the national level (Bluhm &

Heineman, 2007). Deliberate modifications to re-fashion what is normal in both instances

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Healthcare Ethics

have been undertaken. Activists in both groups, assisted suicide and anti-smoking have

targeted efforts at the state level through tort law and the use of the ballot (Bluhm &

Heineman, 2007). Individual autonomy or the right to chose ones own actions and

destiny is paired with humanitarian ethos (Mappes & Zembaty, 2007). In both the anti-

smoking debate and in Euthanasia or PSA, PAD suicide, respect for individual choice

should be provided and granted if no other individual is negatively effected (Mappes &

Zembaty, 2007). This in both is a form of deontological ethics.

Seeking governmental assistance is a significant method of activist as well as

those who proclaim the opposite of a legislative/Judicial “slippery slope” (Bluhm &

Heineman, 2007). Reaction from congress from anti-smoking activists was mixed

wherein more success was achieved through the states, which is what pro-assisted suicide

advocates have also experienced. In both cases they were much more successful at

moving policy in favor of their agendas (Mappes & Zembaty, 2007) (Bluhm &

Heineman, 2007).

To illuminate or reduce smoking advocates shifted from the “right to chose” to

“equal rights” or personal autonomy for victims such as the young and non-smokers.

According to Dan W. Brock denying oneself life sustaining treatment and allowing

euthanasia to be applied to oneself should be permissible equally on the grounds of self-

determination or autonomy (Mappes & Zembaty, 2007). These positions of autonomy

and juxtaposed, one in the case of removing a right of autonomy and one giving a right of

autonomy. To the writer if autonomy is a fundamental deontological law then one of

these rights is in error fur autonomy cannot be according to both advocacy groups.

Utilitarianism might find a second flaw with euthanasia based on statistical data.

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Healthcare Ethics

Risk is in itself an expansive component of the debate in all health related issues,

both in the anti-smoking debate and in the suicide debate. There are risks in smoking, in

breathing second-hand smoke, in driving, in all things associated with life and in how we

die, not only in end of life decision making. According to advocates for physician

assisted suicide no new risks are introduced with the new polices that would not be

already present in the current policies (Mayo & Gunderson, 2006). Informed consent is

already an integral part of all medical decisions involving one self as well as including,

medical power of attorney, wills, living wills and DNR’s. The explosive growth of

technologies from 1960 until currently that prolong life has made the value of life as

unique turn toward aggression and medical vitalism that is paternalistic, causing as much

or more harm that should be (Mayo & Gunderson, 2006). According to Mayo

utilitarianism is used as a risk-based fork for those against PAD or PAS away from the

true issue of medical vitalism (Mayo & Gunderson, 2006).

Utilitarianism proposed by Jeremey Bentham is measured by a calculus of

pleasures and pains and not by intentions. This calculus for a social good to actually be

socially good must add up to a net sum of pleasure over pain or the good of the many vs.

the good of the few (Bluhm & Heineman, 2007). One major flaw in this calculus is that

of the value of a pleasure or a value of a pain (Mappes & Zembaty, 2007).

Statistically though for euthanasia, policy, and assisted suicide data tracking can

be used to follow the path of this policy and some possible impetus for health care

insurers with references to the smoking debate. Declining health is a factor in up to 25%

of all suicides with 50% of them in people over 50 and expanding to 70% in people older

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Healthcare Ethics

than 60 years of age (Roleff, 1998). Statistically in 95% of all suicides, a diagnosable

psychiatric illness is present within just a few months of death (Hendin, 1997).

Statistically the converse slant of anti-assisted suicide, euthanasia can be

determined. With the Dutch/Netherlands system of euthanasia upwards of 75% of

assisted suicide requests from doctors are declined by them due to issue beneath the

request such that counseling or symptom control are adequate (Watts & Howell, 1992).

In 1990 some 66% of those who responded to a Gallup poll in the US regarding assisted

suicide for those who were terminally ill a moral right (Watts & Howell, 1992). This

figure had increased from 45% during 1975 (Watts & Howell, 1992). Finally in the

Netherlands, where assisted suicide has been fully implemented for some time, only 2%

of all deaths are those due to euthanasia (Watts & Howell, 1992).

In 1990, 1250 cases of explicit intentional doctor assisted suicide occurred but by

1995 the total was 1900 (Hendin, 1997), upwards of 80% of these suicides had no death

requests for termination. With Oregon, a study done by Louis L. Miller 1996 revealed

51% support the Oregon Death with Dignity Act with 13% greater support since 1994.

Again, the study was repeated in 2001 with Hospice nurses 16% more supportive of

ODDA then in 1994 with an increase of 24% for social workers as supportive of ODDA

as well. This expanding attitude has the potential to undermine hospice care in the near

future.

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Healthcare Ethics

(Miller, 2004)

Economically it can run upwards of 40,000 dollars to provide palliative care to a

dying patient but only 40 dollars to assist a suicide of the same patient (Smith, 2005).

Kaiser/Permanente issued an email statement to its northwest division doctors, upwards

of 800, urging them to use PAS methods of Physician Assisted Suicide as a cost saving

technique (Smith, 2005). The savings nationally from PAS intervention would be in the

hundred of Billons of Dollars and would drive assisted suicide by profit (Smith, 2005). In

1998, the Oregon State Health Commission provided funding within its plan structure for

PAS reimbursement for those who were poor and were under the State run plan. Finally,

it can be noted that only 5% of all of Oregon’s suicide cases in total within 7 years had

obtained psychiatric counseling (Smith, 2005).

Under the utilitarianism, filler pleasure would be maximized as viewed in cost

savings by HMO’s, PPO’s, and state funded health plans, while statistically safeguards

are not adequately present. In human life utilitarianism palliative care and not expense

savings agents would maximize pleasures in favor of poor under privileged dying

patients. Considering those to gain the most monetarily are those administering PAS, this

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Healthcare Ethics

would create a conflict of interest. Again, assisted suicide and Euthanasia do not meet the

mark of utilitarianism, not from a patient standpoint

Libertarians under the auspices of the definition of the libertarian’s ethic: 1.

Believe in free will that is not to be abridged by the state. 2. The individual interest

should not be abridged for the mass. In the anti-smoking’s ban in NY and that of the

Oregon PAS law both actually produced greater layers of policy and personal rights

reduction. This is not to say a containment of second hand smoke is not without good

warrant. In October of 2003 fines were implemented to those bars, taverns, and

restaurants that do not comply with the statewide clean-indoor act ban on smoking

(Bluhm & Heineman, 2007). According to the Empires State Restaurant and Tavern

Association they argue that the policing and compliance of the law is left to the

restaurants and bars. If it is enforced, it is enforced by the local county health department

(Bluhm & Heineman, 2007). With the Oregon PAS and the Dutch model, review

committees had to be complied, a second doctor consultation, oral requests, written

requests, support for other alternatives, possible counseling, and fixing a time of death

(Mappes & Zembaty, 2007). At some point ones expanding of free will infringes on

another’s. At what point is the free will of the mass abridged by the few?

We have cases where one person’s rights infringe upon another’s. We have issues

where logic can fight logic and statistics can fight statistics. Because we are as a society

ever more struggling with fewer resources, we have splintered into focus groups, interest

groups and lobbying groups. In the case of smoking, a right to smoke was taken away,

albeit due to health hazards. The smoking debate is only an illustration to illuminate PAS,

PAD and Euthanasia. In personal autonomy to decide, death rights attempted to be given.

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Healthcare Ethics

Consistency is found in America’s special interest groups to have rather than to give. We

want to be free of smoke and we want the right to decide what to do with our bodies, but

what of someone other than me or us, perhaps, you or them? Do all decisions need to be

codified, to be written in law? As for euthanasia perhaps we can keep the decisions

informal, a poorly kept secret between the person and his or her doctor (Harber, 2000).

When did the value or an oral commitment fall?

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Healthcare Ethics

Bibliography

Bluhm, W. T., & Heineman, R. A. (2007). Ethics and Public Policy: Method and Cases.

Upper Saddle River, NJ: Pearson Education Inc.

Harber, J. G. (2000). Physicians Should Grant Requests for Assistance in Suicide:

Greenhaven Press.

Hendin, H. (1997). Physician-assisted suicide: a look at the Netherlads. (Dutch

acceptance of euthanasia). Current(398), 25-26.

Mappes, T. A., & Zembaty, J. S. (2007). Social Ethics: Morality and Social Policy

(7th ed.). New York: McGraw-Hill.

Mayo, D. J., & Gunderson, M. (2006). Legalizing Voluntary Euthanasia Would Not

Harm the Disabled. Opposing Viewpoints Resource Center.

Miller, L. L. (2004). Proportion of Oregon physicians, nurses, and social workers

in support of and opposition to the Oregon Death with Dignity Act, 1999 and

2001: Palliative Medicine.

Roleff, T. L. (1998). Effective Pain Management Can Prevent Assisted Suicide. Journal.

Retrieved from http://find.galegroup.com.library.esc.edu

Smith, W. J. (2005). Assisted Suicide Would Be Mandated for Economic

Reasons. San Diego: Greenhaven Press.

Snyder, C. (2006). Oregon's Assisted Suicide Experience: Safeguards Do Not Work

(Publication. Retrieved 3/10/2008, from Gale Cengage Learning:

http://find.galegroup.com.library.esc.edu

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Healthcare Ethics

Watts, D. T., & Howell, T. (1992). Assisted Suicide is Not Voluntary Active. Journal of

the American Geriatrics Society, 40(October), 1043-1046.

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