Imagine, for a moment, that you have a terminal pulmonary disease. Your final breaths grow shallower. The period between your breaths grows longer. You are slowly — agonizingly slowly — suffocating to death.
Imagine, for a moment, that you have a terminal case of cancer. Your final moments are spent either in excruciating pain as the cells in your body battle themselves to exhaustion, or in an incoherent morphine haze. You can’t move. You can barely and seldomly speak. There is nothing more in the world you want than for the pain to be gone, once and for all.
Many people have a line they do not wish to live through seeing crossed. Many people, myself included, have a level of suffering they have no desire to experience or share with others. If or when that lines approaches, many of us would choose to simply opt out — to, and I’m not going to sugarcoat this, commit suicide — with or without the assistance of trained medical personnel or the express statutory permission of the government.
In 10 states, as well as Washington, D.C., terminal patients may ask for Medical Aid In Dying (MAID) — or, less euphemistically, physician-assisted suicide — when they reach that line. If SB239 passes, Nevada will finally, after five sessions and over a decade of effort, join them.
In a recent poll, 84 percent of Nevadans agree that a mentally capable adult patient with an incurable, terminal illness, who only has six months or less to live, should have the legal option of medical aid in dying — or, if you prefer, physician-assisted suicide — to pass peacefully in their sleep. Additionally, 98 percent of Nevadans agreed that patients, in consultations with doctors and loved ones, should be the primary decision maker on end-of-life options, including how we die.
If you, like me, are in that 84 percent, you don’t need further convincing.
The remaining 16 percent, however, is consistently overrepresented in our state Legislature and in our executive branch. Past efforts to pass similar bills either failed due to promised vetoes from whichever governor was in power or due to legislative inaction. Even now, only 11 of the 21 senators who voted on the measure voted in favor of SB239 — that means 48 percent of the Senate opposed a measure only 16 percent of Nevadans oppose.
Consequently, I am consciously choosing to meet that 16 percent of Nevadans — or the substantially larger minority of Nevada’s legislators — on their own terms. As a recent article regarding the bill in The Nevada Independent points out, opponents of the measure believe the bill’s framing is all wrong. The bill doesn’t legalize “medical aid in dying” — it’s legalizing physician-assisted suicide.
Very well, then. Let’s discuss why Nevada needs to legalize physician-assisted suicide.
To be bluntly earnest, my first instinct, when approaching this subject, was to respond with unhelpful righteous indignation. Who do you think you are to play God with my body? What gives you the right to decide whether I live or die?
This instinct is unhelpful because I know the answer. If you oppose physician-assisted suicide, you do so for my own good, the good of my family and the good of society as a whole. You’re not unsympathetic to the suffering of those undergoing traumatic, horrifying end-of-life situations, nor to the pain they’re enduring in their final moments. You just believe that a world in which anyone — whether that person is a physician, a family member or even the patient themselves — is empowered to end their life will become a worse, less humane world, regardless of any safeguards anyone promises to put into place.
What if the terminal disease is only incurable now, but a cure is released in the next six months?
What if family members pressure a terminally ill patient to end their life because they don’t want to take responsibility for the patient’s end of life care?
What if the patient’s insurance provider refuses to pay for life-saving care because physician-assisted suicide is better for the bottom line?
The last question, at least, is easy enough to address by asking a couple of follow-up questions: What if Dr. T. Brian Callister, an internal medicine specialist and hospitalist and long-vocal opponent of physician-assisted suicide, is opposed because providing end-of-life care financially benefits him? What if the American Medical Association, which opposes physician-assisted suicide, is opposing physician-assisted suicide for the same reason it opposed Medicare in 1964 — because it’s bad for business?
Now, before the friends, family and satisfied patients of Dr. Callister bombard my email inbox — no, I don’t seriously believe Dr. Callister’s opposition to physician-assisted suicide is motivated by the promise of financial remuneration. On the contrary, I strongly suspect his moral convictions to do right by people in their final moments led him to pursue a career in the field of end-of-life care.
The questions are meant to raise an important point. It’s more than a little dehumanizing to reduce someone solely to a surface-level understanding of their financial incentives, whether that person works as a medical provider or in health insurance. If we are going to consider incentives, however, it’s important to do some double-entry accounting and consider the incentives that medical providers, as well as the doctors employed or contracted by them, work under as well.
Yes, it’s absolutely true that insurance companies, private and public, frequently refuse to provide expensive care, lifesaving or otherwise. That was happening before physician-assisted suicide was legalized and will undoubtedly continue to happen whether physician-assisted suicide is legalized or not. That failure to reimburse for care is an important part of the reason why, according to a recent report released by the Consumer Financial Protection Bureau, medical debt accounts for 57 percent of the debt that ultimately goes to collections — debt that is sold to third parties who specialize in delinquent debt collection.
In many states, medical debtors have even been sent to prison for failing to cooperate with debt collectors to their arbitrary satisfaction. In Kansas — where physician-assisted suicide remains illegal — a local judge effectively granted a local medical debt collector the power to arrest debtors who, in the eyes of the debt collector, were insufficiently cooperative with the debt collection process. In Virginia — where physician-assisted suicide also remains illegal — the publicly run University of Virginia Health System filed 36,000 lawsuits during a six-year period, through which it gained the power to garnish wages and seize the homes of former patients.
Even during the pandemic, hospitals relentlessly pursued aggressive medical debt collection practices.
The pervasive existence of medical debt illustrates two important points.
First, just because an insurance company doesn’t choose to pay for a specific procedure, that doesn’t mean patients don’t receive treatment. On the contrary, as I myself learned the hard way a bit over a year ago, hospitals are quite happy to provide treatment, regardless of whom or whatever is ultimately responsible for the bill — though good luck finding out what that bill will be in advance.
Second, medical providers — or at least their billing departments — aren’t necessarily the good guys here. AB469, which passed in the previous session and sought to address surprise hospital bills, implicitly functions under the assumption that the rates hospitals and other medical providers charge to insurance providers and patients are negotiable — or, if you prefer, invented almost entirely out of whole cloth, with only the thinnest, most tenuous connection possible to the costs incurred to provide service.
Much of the time, in fact, medical services aren’t provided at all. A recent article in The American Prospect revealed how several hospice providers — the companies responsible for providing palliative, instead of curative, end-of-life care — collected millions of dollars from Medicare in exchange for doing absolutely nothing at all. Or, in some cases, worse than nothing — intentionally overdosing patients with opiates so they die before insurance runs out (or starts asking uncomfortable questions about why the supposedly dying patient receiving hospice care isn’t, in fact, dying) isn’t entirely unheard of.
Unsurprisingly, insurance companies — and the people who work for them — would rather reimburse claims for actual helpful medical services than thinly veiled narcotic pill mills or naked graft. Sometimes they overcorrect, it’s true, but consider who they’re going up against and what their incentives are.
Regarding uncaring family members, meanwhile, it’s a rare person who isn’t aware of their family’s opinion of them or how willing — or able — their family might be to effectively care for them. In some circumstances, knowing that there’s a path available to prevent a knowingly solicitous family member from taking advantage of their position of care is a relief. Elder abuse and elder fraud are quite real and quite pervasive. Giving patients an additional choice and opportunity to escape manipulative “caregivers” while they’re still capable of making choices and taking opportunities is a blessing, not a curse.
Finally, regarding miracle cures delivered at the last second — curing the disease rarely cures the damage caused by the disease. Though brain cells can regenerate, a cure for Alzheimer’s or Lewy body dementias won’t cause dead brain cells to immediately grow back. Even successful cures for cancer leave previously healthy patients exhausted and damaged. After a certain point, some patients might not want to be cured — not if “being cured” means being permanently stuck in a radically degraded physical and mental state for the remainder of their days.
The choice facing Nevadans, then, isn’t between an utopian present where insurance companies faithfully reimburse medical expenses, all of which are wholly and obviously necessary, versus a dystopian future where insurance companies maximize profits by pushing all but the richest Nevadans into “volunteering” to become Soylent Green. Quite the contrary — the choices facing many patients today are simultaneously Faustian and Kafkaesque.
Do they accept the recommendations (and corresponding bills, whatever they might turn out to be) of their medical providers, with no possible understanding of who’s going to pay for them, nor how much they’ll cost?
Do they take experimental therapies — access to which, for the record, I wholly support — and hope there will be enough of themselves left on the other side of the cure, if it exists, to enjoy their good fortune?
Do they enter hospice care — a field increasingly rife with profit-maximizing and insurance fraud — with the hope that someone, somewhere might double check that they’re actually receiving the care they’re supposed to receive before they die, all while primarily relying upon the time, kindness and physical strength of their family and friends?
Do they spend the money to travel to Switzerland, where physician-assisted suicide is broadly available, even beyond the scope of what’s being proposed in SB239 or implemented elsewhere in the United States? Do they instead spend a little less money to travel to California, Oregon or one of the other states where physician-assisted suicide is already legal under limited circumstances?
Are they even physically able to travel?
Do they just die in pain and agony alone, with no one around to care for or even notice their absence?
Or do they use their one last final gasp of strength to end their suffering using whatever tools and methods are immediately available to them, no matter how inhumane or ineffective those might prove to be?
It’s true that legalizing physician-assisted suicide won’t improve the incentives between insurance and medical providers. Physician-assisted suicide isn’t an everything bagel — it won’t fix all of the malincentives present in the American medical system.
What SB239 will improve is far more immediate and straightforward: Will a patient undergoing constant, unremitting pain and suffering reach out to a physician or to a gun dealer? Will a patient nearing the end of their life call a doctor or crawl into their car in their garage one last time?
Those aren’t academic questions. People facing the grim, painful finality of their lives are committing suicide right now, many without a physician present to ease their suffering — or to talk them out of it.
Patients can’t be the primary decision maker on end-of-life options if the government refuses to permit the existence of a decision. Patients can’t consult with doctors or loved ones about their end-of-life preferences if the consultation itself is illegal. Legalizing physician-assisted suicide gives patients and consenting physicians one more choice — and one more chance to make a different choice.
David Colborne ran for office twice. He is now an IT manager, the father of two sons, and a weekly opinion columnist for The Nevada Independent. You can follow him on Mastodon @[email protected], on Twitter @DavidColborne, or email him at [email protected].
