Oregon Death With Dignity Act

Oregon Death With Dignity Act

America spends 50% more on health care as a percent of GNP than any other country. Those countries closest to the U.S., France and Germany, each spend 10% of their GNP (EIU, 2007). Sixty percent of an American's healthcare expenses take place in the last year of life. Forty percent of all Medicare expenses are spent on the elderly in the last month of their life (PBS, n.d.).

These figures are significantly higher than in other developed countries. Although we in the United States claim that we have the 'best healthcare system in the world,' our people do not live longer than in other countries. In fact, the U.S. lifespan is below other countries which spend a lot less on healthcare, including Japan, France, Finland and Canada (EIU, 2007). While not all countries have the same demographics as the U.S., one can nevertheless question whether the United States provides such expensive end-of-life healthcare as other countries.

Part of the reason for the difference may lie in culture. The U.S. has a much higher rate of 'massive' intervention in cases, and rates of procedures are much higher in the U.S. than other developed countries. While many Europeans and Japanese accept that a patient is dying of a fatal disease, Americans (including the patients, patients' families and their healthcare providers) are much more willing to undergo dramatic treatment options, even when it is a foregone conclusion that the patient will die. In the absence of an express will of the patient not to undergo drastic measures, the court system and the interventionist mindset of the healthcare providers conspire to create an impetus for intervention.

Another aspect of the U.S. cultural attitude towards death is the contrast with Germans, French and Japanese (Klein, 2007). The Taoist and Buddhist attitude towards death is that it is a natural part of life. In general, Japanese physicians and the patients' families accept that the patient should be made comfortable, but no drastic actions should be taken to extend the patients' life a few days or weeks if there is no hope of improvement.

Some who have had a chance to experience different cultures have delved into this subject. A recent study of Italians, for example, found that most (62%) preferred dying at home amongst family than in the hospital (7%) (Crisci, 2001). In the Netherlands, informed-consent deaths have been permitted for a number of years. Many physicians interviewed prior to the passing of this legislation said that it simply codified what they had been doing for years.

One may make the argument that a cost argument in the context of health care delivery during a patient's dying days may be unethical, or at least distasteful. This paper does not argue for forced euthanasia; rather, it argues that allowing a patient to die of his/her own volition is a better use of healthcare facilities than taking heroic measures to prolong life, regardless how painful, demeaning or without purpose.

The decision to take drastic measures could be attributed to the bulk of the U.S.' outsize spending in healthcare. If Germans, French and Japanese spend 50% less per capital and per GNP than the U.S., they also spend a good deal less on end-of-life measures. That does not mean that life is ended prematurely, or that patients are put to death against their wishes.

If the U.S. were to consider allowing patients to make decisions about undergoing or forsaking drastic medical care in the dying phase of their life, the healthcare system could save a great deal of money. These resources (money, physicians, nurses, healthcare facilities) can then be devoted to other, more pressing needs which have an actual impact on healthcare, quality of life and life expectancy. Among these areas where the investment pays off in better overall healthcare:

Better pre-natal care for women, in order to prevent underweight babies, premature birth, birth defects and drug-addicted babies.

Better diabetes care on an outpatient basis to insure that patients establish and maintain routines which reduce the ravages of diabetes (circulatory, other).

Screening for diabetes, heart disease, breast cancer and other diseases which are not met by much of the health system today.

Thus the choice is not "save money by allowing patients to die." The choice is, rather, "allow patients to die rather than taking heroic measures, and redeploy these scarce resources to improve overall healthcare, quality of life and lifespan."

Nurses are required, as one of the 9 conditions of their oath, to triage and rationalize the giving of healthcare. If an ER nurse, for example, has a series of patients with whom she can only deal one at a time, he/she must make the 'triage' decision to focus on the patient who can benefit from his/her care the most.

That means that not all patients can receive the same level of care.

Lost in the debate about Oregon's "right to die" legislation is that the State of Oregon also embarked on a thoroughgoing analysis of healthcare rationing. The state disallowed a number of categories of medical treatment, and cut back on a number of other such methods, in order to free up resources to focus on the sicker patients. The overall goal was to support procedures and the use of resources in such a way that healthcare was enhanced. The right-to-die legislation was part and parcel of this overall effort. Those backing the legislation in the State understood that heroic expenditures at the end of life were not only futile, but they diverted scarce resources from other areas where the patients could be better-helped.

The better way to present the ethical dilemma is as follows: "Does it make more sense to invest in preventative healthcare, for everything from nosocomial infections and breast cancer to prostate cancer and diabetes, or does it make more sense to spend those resources on prolonging dying patients' lives in hospital beds for a few days or weeks, particularly if the patients would not choose to go on living?"

Americans are changing their attitudes towards death and dying, which may augur well in other states for right-to-die legislation (Journal, 1981). What is less likely to change in the short-term is our medical system's attitude towards intervention. American physicians are much more likely to perform hysterectomies, cardiac catheterization, cardiac bypass operations, hip replacements and many other procedures than their European, Canadian and Japanese counterparts (NEJM Editorial, 1994).