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Choice Devours Itself: Euthanize early or else!

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.

HT Wesley J. Smith

Comments (13)

Excellent Post, Lydia. Leon Kass once posed the question perfectly: "Is it medicine to make sure there is no patient?" That's what we're looking at.

Thanks, Neil. Yes, in states that do have doctor-assisted euthanasia, it's been interesting to see how this has intersected with the concept of medical propriety. For example, many doctors don't want to participate, and there is a lot of impatience with them. Wesley J. Smith has pointed out repeatedly that under Oregon law the doctor is required to falsify the cause of death. If the person has died of an overdose of drugs under the state assisted suicide law, the cause of death is supposed to be listed as whatever "underlying condition" the patient had rather than the overdose of prescription drugs. This is a corruption of medical integrity from every point of view.

You should regard this for what it is: a way for a liberal to feel good about himself for cutting off access to a program he feels is morally sacrosanct. This is how policy wonks do cognitive dissonance when their sacred cows are eating up all of the grass on the commons right before rain season is set to cause a mud slide. However, I don't think it should be seen so much as a cruelty as it is a painful reminder that left-wing positions are becoming so unsustainable that even the left is starting to have to find ways to get out of the bed they've made for themselves. Heck, even the NHS is saying that the time for "free healthcare" is coming to an end in Britain because even they cannot sustain it.

I agree with you that in actual effect Leeson is a liberal, but this is in no small part because he is a *social* liberal-- e.g., because he's strongly pro-euthanasia and sneers at moral objections to euthanasia as "religious." I'm pretty sure there are people who regard him as a conservative. Now, that's silly, because for one thing if he were a really rampaging conservative even of the economic stripe he'd be looking for much less ideologically freighted, more across-the-board, ways to phase out or greatly reduce the very existence of a ginormous government program as Medicare. These would also have more important economic effects. But such is the strange use of terms nowadays that I'm sure there are many who will regard this column as an example of fiscally conservative or libertarian thinking!

Of course it's cruel, as well as wicked (those two not necessarily being the same--not all wicked things are cruel), because it's an attempt to get people to kill themselves rather than living "lives unworthy of life." That it is _allegedly_ motivated by economic considerations doesn't make it anything other than a _morally_ driven position. After all, you don't see him, at least not here, fretting about all the money wasted on unnecessary cancer screening for the young. It's because he places a low value on the lives of the old and disabled that he's making these suggestions.

What's pernicious about it, in addition, is the pretense of advocating choice when actually he's advocating something quite other than free choice.

I still say cognitive dissonance is a better explanation than malice. The elderly issue is the gravest challenge the left has to its notion that health care is a human right because it's threatening to eliminate all other goods to achieve it. To me, this has all of the markings of a strategic retreat and regrouping. In his mind he probably believes he's not sacrificing that liberal ideal, he's just "making them realistic." Obviously he's sacrificing it and in a grossly immoral way, but he has to avoid the fact that all across the industrial world no health care model that treats health care as a human right ensured by the state is viable given demographic trends and other issues.

There certainly _is_ cognitive dissonance, specifically, the cognitive dissonance between his claims of freedom of choice and his actual proposals. I don't know exactly how you define "malice," but what is quite certain is his devaluing of the lives of the people in question and the fact that that influences the form his policy proposals take. I myself would call that a form of malice, but you introduced the word, and it's not a word I'm interested in arguing about. Here are a few more quotes from the article:

A large proportion of health care resources are allocated to a system in which the dying have their bodies - but rarely their lives - prolonged:
Bodies can be kept alive long after life has any connection to conventional quality-of-life measures. While still free to choose, many would prefer secular "immortality" to a lingering, humiliating and incapacitated drift toward a rapidly approaching death.

The contempt there for the lives of the people in question is pretty blatant. Why, on Leeson's view, they might as well be regarded as dead. Their bodies are continuing but not their lives. Ain't that sweet?

Choice devours itself, example no. 1637: A (half)joking pitch for mandatory abortion from the awful Dan Savage:


I know, NM, that one was pretty much a perfect example. As Wesley J. Smith anticipates when he mentions this story, people will say it's just Savage being "provocative" and doesn't count. But as Smith also points out, the idea is more mainstream than many would like to admit.

What's fascinating about it is that Savage doesn't remotely "get" that he's being intolerant and authoritarian. Liberals are blind to their ideology's own tyrannical nature.

Mandatory abortion? Sure. Let's start with all of the residents of the big cities first, since that's where the population is centered. While we're at it, let's also go Logan's Run on them. Cuz everyone over 30 is just a fat socialized medicine hospital bill waiting to drop on the public.

Oh, I dunno. I think Savage gets that he's being tyrannical, which is why he cheerfully calls it a dangerous idea. I think he gets a bit of a high from that. Savage strikes me as the kind of fellow who at some level enjoys being a bully. We've seen evidence of that before in his treatment of Christian students.

Savage strikes me as the kind of fellow who at some level enjoys being a bully.

He's a prominent gay rights activist, so that's all you need to know about that.

Savage may be a bully himself, and probably realizes it, but I'd imagine he believes he's being one in the service of a higher good, tolerance. What he doesn't get is that his version of tolerance is itself tyrannical.

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