John La Puma, M.D.

John La Puma, M.D.

Polls consistently show that 60 percent of the American public favors the option of physician-assisted suicide. Recent surveys of American physicians in Oregon and Michigan show that many doctors favor it too, as long as there is legal protection.

Discussions of assisted suicide are among the most personal conversations. They test our individual understanding of compassion, ethics and moral responsibility. Ethical issues raised by physician-assisted suicide cover the 20th century waterfront, from the right to die and proxy decision-making to physician professionalism and access to treatment.

How does managed care affect these four issues?

Right to die

Within managed care organizations, every member has a right to the organization's services. Should managed home care include assisted suicide services, or should they be part of demand management? Should hospice care be part of those managed care services, and should seminars on pain management become a continuing medical education requirement? Should Dr. Kevorkian's little plastic clip become durable medical equipment? Should health systems consider outsourcing this particular assessment, or will they have the expertise to develop their own programs?

These questions about rights to treatment are perverse, but rights are interpreted as legal matters in our society, and conjure up thoughts of demands and suits.

Many medical ethical issues present as disagreement, and "rights" are sometimes invoked to settle them. Medical ethicists have often emphasized consensus-building — not "fighting for what's right" — as a way to solve clinical problems.

Medical ethicists have also taught that there is no legal right to die. Now, we're not so sure. The 2nd and 9th Circuit Courts, within just a few weeks of one another, have suggested that there is a constitutionally protected right to die.

This newly interpreted right to die is paradoxical, at best. There is no "right" to treatment in the United States, except in Veterans Administration hospitals, federal prisons, hospital emergency departments and managed care organizations.

Especially in managed care, we seem more interested in making sure patients don't get treatment they don't want than assuring they get treatment they need — whether conventional, alternative or experimental. Perhaps the right-to-die movement can show the managed care community that this understanding is backwards.

Proxy decision-making

The federal Patient Self-Determination Act of 1990 requires that HMOs and hospitals, among others, ask whether a patient has an advance directive. Is there a designated decision-maker in case of an incapacitated patient? Such a decision-maker, 1990s reasoning goes, ought to represent what the patient wants, not what the proxy or family wants.

Data from the Netherlands indicate that physician-assisted suicide and euthanasia are disturbingly common among patients whose proxies request it for them. Holland is economically and socially homogenous when compared with the United States, and the financial pressures that managed care highlights here are nearly absent.

If we lived in a culture in which family-centered decision-making were well accepted, American physicians might accept proxy requests for assisted suicide as equivalent to the requests of patients.

Yet in our current logical, dichotomous way of thinking about right and wrong, such proxy, perhaps family-oriented requests seem inappropriate, and the violation of patient automony seems blatant.

If the Dutch experience of proxy decision-making for assisted suicide and euthanasia translates at all, the principles of population-based health and fairness to others have a long way to go for acceptance in managed care.


Professionalism is what we have that other workers don't, and it is a do-or-die issue for physicians. Honest, well-meaning physicians disagree on whether we should help patients die. Some, like Timothy Quill, have become strong advocates for this view; others, like Edmund Pellegrino, have always been rigorously opposed.

There are arguments both ways. On the one hand, physicians should make it possible for their patients to take their own lives in exceptional circumstances with specific, triple-checked, publicly known criteria. On the other hand, a pa- tient's request for assisted suicide is often a symptom of the problem (from clinical depression to substandard palliative care) rather than a solution.

Whatever we might think about assisted suicide, managed care counts on physician professionalism as much or more than any other delivery system. A patient must be able to trust a doctor's judgment, derived from that patient's medical condition and personal circumstances. The financial incentives to physicians to limit care cannot be allowed to influence, much less distort our professional judgment, especially near the end of life.

Access to treatment

It is outrageous to posit access to a doctor's assistance in dying but not in living, especially for disadvantaged patients. Care for those who are living deserves the same protection as care for the dying, even if they are only equally important.

Managed care responds to a health care system that has previously paid for medically indigent care with cost-shifting from the rich to the working poor. Even within a managed care organization, indigent patients are less able to pay for services and may not know how to argue for treatment to which they are entitled. It goes almost without saying that most such patients are women and minorities, some of whom had trouble gaining access to care in the first place.

'The lowest-cost solution'

Yes, there should be quality parameters and performance standards for gauging promptness and helpfulness in assessing and treating pain and suffering, for alleviating family burden, and for improving patient and family satisfaction with these tasks. But no, assisted suicide in managed care is not the answer. It is, however, the lowest-cost solution to nearly any patient problem. Separating ethics and economics is the least we can do.

John La Puma, M.D., practices internal medicine with North Suburban Clinic in Elk Grove, Ill., and is a Chicago-based speaker and educator. With David Schiedermayer, he is the co-author of The McGraw-Hill Pocket Guide to Managed Care: Business, Practice, Law, Ethics (McGraw-Hill, New York, 1996).

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