It's a rare but instructive opportunity when someone acting out the choice devours itself dynamic makes his "reasoning" explicit. This recent editorial in the SF Chronicle provides such an opportunity. Economist and obvious social liberal Robert Leeson (who is a visiting fellow at the "conservative" Hoover Institution think-tank) suggests a faux "choice" approach to euthanasia. His statements are a tad cryptic, but read them for yourself and tell me if I'm misinterpreting.
Economists typically assume that individuals seek to maximize their lifetime satisfaction - yet, when it comes to voluntary euthanasia, the law prohibits such a decision. Moreover, many dying people are beyond the stage where they can act according to this calculation; younger people are much better equipped to make this rational choice in advance.
At the beginning and the end of a working life, individuals should be free to decide about such matters. At the beginning, there might be a choice between buying end-of-life insurance (maybe with pre-tax dollars) in return for a reduction in Medicare tax; or accepting that end-of-life costs will be charged to - and recouped from - their estate. And at the end of a working life: a choice between receiving end-of-life care, or allocating those funds to grant oneself a metaphorical "immortality."
For those opting out, such "immortality" could be provided through an annuity - an eternal income to a worthy cause of the individual's choosing (a "named" scholarship, an annual charitable contribution, etc.). The end-of-life privately insured could be offered a cash payout in return for surrendering their policy. (Or public and private insurance could offer both choices.)
There can be no objection to someone choosing to self-fund palliative care; neither can there be an objection to the taxpayer choosing to fund, for example, better infant mortality outcomes than end-of-life expenses.
As I understand Leeson, he suggests the following package of policies: Make euthanasia legal throughout the country. Have the federal government take all "end of life care" (however that is defined--I'll discuss that problem below), including palliative care, off of the list of things covered by Medicare. Make available end of life rider insurance, which people can purchase with their own money paid on top of their Medicare taxes during their working years, for those who don't think they will want to be euthanized. Anyone who does not purchase such extra end-of-life insurance and hasn't made other provisions for funding his end-of-life expenses will have his end-of-life expenses charged to his estate after his death (since they weren't covered by Medicare). When people are elderly, if they have purchased such an end-of-life rider, offer to buy the policy from them for a cash payment in return for their willingness to be euthanized. If they have not purchased such a policy, still bribe them to be euthanized by offering a "metaphorical immortality" in the form of an endowment to a worthy cause in their name in the amount of the putative amount that their remaining years of life were allegedly worth.
Let me stress that this proposal does not arise from some sort of principled objection to Medicare as such from a free market perspective. It is end-of-life care that is to be selectively targeted in a blatant attempt to induce people to bump themselves off. Medicare otherwise would continue, but end-of-life care would be treated as specially non-coverable. Presumably because people who get other Medicare payments are doing something legitimate but people who get Medicare payments for end-of-life care are acting as parasites on the system.
Leeson uses the words "choice" and "free" several times in the course of proposing this monstrous policy package, but he makes no secret of the fact that the choice being made would be deliberately nudged by policy in the direction of early euthanasia. The offer to pay people to be euthanized is an un-subtle form of encouragement, but even more than that, the fact that end-of-life care, in contrast to other things covered by Medicare, must be self-funded for the elderly, is a deliberate attempt to push people off the cliff.
Leeson is so eager to get people dead that he doesn't even bother to make the distinction, which even our death-hungry present medical establishment recognizes, between palliative care and other end-of-life care. He's afraid even palliative care would keep people alive too long and hence wants it penalized as well as "end-of-life." The irony here is that (perhaps unbeknownst to Leeson) "palliative care" as presently used by our medical establishment doesn't include food and water, so when someone is put onto it he's usually safely dead in two weeks anyway. But what the heck! We want a "clean bill," as it were: Let's make sure people just die definitively and all at once instead of taking two weeks.
The proposal is crazy enough on its face but looks even crazier the longer one thinks of it. Suppose, under Leeson's plan, that Grandma is puttering around just fine, taking heart medication but otherwise getting along okay, and one day her dicey heart gives out on her altogether and she's found dead in her own home. Is there any end-of-life care there? If Medicare paid for everything already, is there a clawback from her estate for all expenses that in fact happened to fall within her last year of life? Or do we count end-of-life care only if and when some diagnosis has been made that doctors believe allows them to predict death within a certain time period? What time period? Does Alzheimer's count? What if a person is in a coma but, with ordinary care (such as food and water) lives for five years? What portion of that counts as end-of-life care? What about people who are on Medicare when young because they are severely disabled and unable to work? Does this "get euthanized early" scheme apply to them? What about those who are mentally disabled? Do others get to make the "get euthanized early" "choice" on their behalf?
Leeson justifies the high-pressure aspects of his plan by the following "reasoning":
Medical co-payments assist rational decision-making: the private, unarticulated conversation that mumbles on in one part of our brain is confronted by the external reality of incentives (costs). This external conversation leads to actions that more closely resemble reported desired outcomes (for example, many tobacco smokers report that they would like to quit, but remain trapped in their habit. Increasing tobacco taxes nudges short-run outcomes toward the desired long-run result.) Public policy should assist such outcomes; without such intervention, the individual will likely make no decision at all - to the detriment of all concerned.
Got that? Government policy needs to "intervene" in order to assist rational decision-making--aka, to get people to make the decisions Leeson thinks are best. And besides, dying early is what most people really want anyway, just like (some? most?) smokers really want to stop smoking. So providing, er, incentives to kill yourself is really just helping people to do what they really want to do deep down at some level that would otherwise remain inarticulate and ineffective.
Rarely has the choice devours itself logic been so brazenly and explicitly displayed. Getting euthanized early should be a choice, because it's something people need to be allowed to do. Actually, come to think of it, it's the only really rational choice, so we should try by means of policy to pressure people to make that choice. But really, it's all about choice. Somehow.
Leeson's scheme would be sufficiently impractical (for the reasons I've already listed) that I doubt it will be put into effect as such. But something like it may well be. For example, in Oregon already the state-funded health care system has sent people with cancer letters saying that the chemotherapy their doctors suggest won't be paid for but that assisted suicide would be paid for. Something similar to Leeson's "intervention" could be made up as we go along. For example, all care expenses for people on feeding tubes might be cut from Medicare. I'm told that already some hospices worry that care won't be covered if they put a person on a feeding tube, though I don't know of any case in which payment has been denied for that reason per se. Medicare coverage could be evaluated by QALY's (quality of life years) on a case-by-case basis, so that Grandpa's life with Alzheimer's is deemed not worth living and hence his care not covered. Add to this the legalization of assisted suicide and euthanasia for everyone, and we have something much like Leeson's system minus the end-of-life private insurance option. In fact, the day may come when his plan looks merciful by comparison with what we actually get.
Years ago when I first proposed the idea that choice devours itself at the old Right Reason site, I had several liberal commentators who scoffed and said that any such pattern existed only in my imagination. Leeson falsifies that claim, at least, fairly decisively.