Several states, including Massachusetts and Delaware, are now actively considering measures that would legalize assisted suicide, joining the five states and the District of Columbia that have already done so. As always, however, various sticks in the mud (such as certain religious organizations and disabled-rights groups) are doing their best to stand in the way. So progress has been slower than many enlightened people had hoped.
Worse, in advocating for assisted suicide, it is the very organizations who stand to benefit the most from it — the third-party payers — who are doing the most harm to the cause. Indeed, it is likely that unless the insurance companies and government agencies that pay for healthcare get their acts together, assisted suicide — even if fully legalized — will never reach the potential its advocates hope for.
The most classic example of public relations malfeasance in this regard occurred in 2008, when the Oregon Health Plan injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care including doctor-assisted suicide.
The national firestorm of outrage triggered by this letter penetrated even the dulled sensibilities of the Oregon insurance executives. Very belatedly, a spokesman for the Oregon Health Plan admitted to ABC News that the letter to Wagner was “a public relations blunder and something the state is working on.”
The Oregon Plan executives were obviously blindsided by the strong reaction against their ham-fisted denial letter. Denial letters, after all, routinely list (as an aid to the patient) services which the insurance company judges to be reasonable alternatives to the denied care. While in this case the denied service offered some reasonable hope for prolonged survival, while the service being offered as an alternative (to say the least) did not, that’s really not so much different from the content of more routine denial letters. The difference is one of degree, and not of substance. So, the executives apparently assumed, the letter should have been perfectly fine.
The executives must have been particularly disheartened to learn that even vocal proponents of physician-assisted suicide widely criticized their ill-considered denial letter. To so blatantly juxtapose healthcare rationing with the option of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is primarily an individual autonomy play, and not primarily a cost-saving mechanism. Even these advanced thinkers agreed that the letter was unseemly. The 2008 Oregon Plan denial letter was catastrophic in every way, and to this day is held up as an example of the kinds of injustices assisted suicide will bring with it.
And so, as a public service to insurance executives in both the government and the private sector who are severely challenged by trying to understand simple human emotions, to patients like Ms. Wagner who may suffer true physical harm by exposure to such institutional callousness, and to the rest of us who simply would appreciate not being confronted so blatantly by the dark abyss that underlies our healthcare system, I hereby offer some friendly advice to health plans on the right way to sell physician-assisted suicide.
I propose a simple, six-point plan:
1) Dont Be So Anxious.
Sure it’s easy to get excited about physician-assisted suicide. Just look at your own data. A huge proportion of your spending goes to patients who are in the last year of life. Enticing these end-of-lifers to choose assisted suicide (which you can accomplish in a sufficiently tasteful way for about $100) is such an attractive proposition that it is indeed very hard to make yourself appear reasonably circumspect about it. At the very least, it’s difficult not to push the idea out there to your subscribers. Otherwise, how can you be sure they know all their options for end-of-life care?
But doing even that much is a mistake. Simply look at the national outrage the Oregon Health Plan unleashed with their simple and helpful reminder letter to Ms. Wagner. It should be clear that for a health plan to seem overly interested in assisted suicide, or even to mention the option to their subscribers, is a potentially counterproductive idea.
2) Publicly Disown Assisted Suicide.
Think about Tom Sawyer whitewashing the picket fence. Ol’ Tom didn’t get all his friends to paint that fence for him by asking for their help, or by overtly selling or cajoling them on the idea. Instead, he got them to do the job by pretending he wasn’t the least bit interested in having them do it, by ignoring them altogether, and making himself seem completely absorbed in the delightful task. By the time Tom was done, his friends were all begging for a turn, and even giving him wondrous gifts (such as dead cats on a string) to bribe him for a chance to participate.
What you need to do is pretend that encouraging assisted suicide, even if it’s a legal and covered service that patients ought to be made aware of, is the farthest thing from your mind. Instead, you are completely invested in and insistent upon providing full-service end-of-life care, with all the bells and whistles and no holds barred; and (while patients, of course, have the option to exercise their individual autonomy as they see fit) you take great pride in squeezing every last instant of life out of those elderly, used-up, chronically ill bodies that present themselves in your ICU, no matter what the cost to the patient and family in terms of pain, suffering, humiliation and anguish. It is your mission to stave off death to the bitter end, come what may, and you’re proud of it.
3) Have Somebody Else Push It.
In the meantime, clear the path for agencies and interest groups dedicated to the end-of-life movement. There are plenty of them out there. Have them do the selling for you.
Make sure they have access to your patients and patients’ families, especially in the ICU setting. Allow them space for educational displays; provide them some private space where they can talk to interested patients and families; see that hospital social workers are aware of their presence. In the meantime, make it clear you do not endorse or encourage their efforts, and indeed wish they would go away, but are providing such groups with access in the interest of full transparency and your dedication to patient choice. If patients choose to avail themselves of such information it’s none of your doing, but you will do nothing to stop them.
4) Make the Advantages Of Assisted Suicide Seem Real.
There’s no need for you to talk up the advantages of assisted suicide; let the end-of-life proselytizers do the talking for you. All you have to do is to make their arguments seem accurate. The great part is, thats just a matter of maintaining business as usual.
The end-of-life zealots will tell patients that assisted suicide is a way of asserting some measure of control over the dying process, of holding on to some level of personal dignity at the very end. So simply make sure your end-of-life care continues robbing patients of any semblance of dignity and control.
They’ll tell patients that assisted suicide will end pain and discomfort and suffering when all hope of recovery is gone. So simply continue with inadequate pain control, and half-hearted comfort measures, and keep the ICU as hectic, loud, scary and impersonal as possible.
They’ll tell patients that assisted suicide will finally bring comfort to their long-suffering family and friends. So make sure family and friends suffer long, by keeping those ICU waiting rooms hot, cramped, noisy, uncomfortable and smelly.
You get the idea. Simply make sure the arguments of the end-of-life advocates have teeth. You’re good at that.
5) Tell Patients To Consult With Their Doctors Before Making This Important Choice.
That’s right. Refer patients to their doctors, their supposed personal advocates, the selfsame individuals you yourself have long since fatally compromised (by grabbing control of their professional viability). Assuming you have placed sufficient cost-cutting pressures on your doctors, then their willingness to encourage (or at least not discourage) assisted suicide will blossom. So when patients do consult with their doctors, the doctors will not undermine your subtle efforts, but will be your partners in convincing those approaching end-of-life to just be reasonable.
6) Make Physician-Assisted Suicide Legal, But Not Reimbursable.
If all you do is follow Points 1 – 5, you will be successful. But Point 6 will take you to a whole new level. Not surprisingly, this is the most difficult and least intuitive step. But just think about it.
You’re going for the Botox model here. You do not want physician-assisted suicide to be merely another hush-hush medical procedure, conducted quietly and almost secretly in a typical hospital room, so that people can pretend it doesn’t exist. Rather, you want to establish it as something that’s front and center, something people will want and ask for and go out of their way to seek. You want to encourage doctors to establish inventive business models for assisted suicide, just as dermatologists have done for Botox clinics.
And as is the case with Botox injections, making assisted suicide a destination service will require you to NOT allow it to become a widely reimbursable medical service. For once it’s made reimbursable, it will become encased in all the price controls, policies, processes, and procedures that hamstring and stifle every other medical service. And you will severely limit the possibilities.
Just consider those possibilities: One envisions physician-assisted suicide becoming established as a “valued life-cycle event,” like a wedding or Bar Mitzvah, where the right atmosphere, the right spirituality, and the right tone come together to create an unforgettable, uplifting experience for everyone. Some assisted suicides will always take place in a medical facility, of course, but why not in a place of worship, a favorite city, a resort, a mountain top, a rocky coast, a casino? Why not allow the prospective decedent to actually hear the eulogies and experience the tearful tributes before actually engaging (ritually) in the Act? Why not partner with the deathcare industry to wrap this final healthcare service into a comprehensive package, including the pre-mortem memorials and post-mortem funeral services? Why not engage American media to celebrate this new lifestyle event with a new mode of reality TV shows (which are sure to garner a massive share of viewers)? Why not convert what is today an antiseptic, impersonal and frightening process into one that makes everybody say, “Yes! That’s the way to go!”
The beauty is that this sort of model will convert what is today, at best, merely the option for assisted suicide into something that’s expected — a true destination event, a natural part of life. Indeed, not opting for assisted suicide, at a certain point in one’s life, will come to be seen as being unreasonable, greedy and selfish. And when granny begins to spend more time in a doctors office, or (worse) in a hospital where frequent visitation is expected (and other family inconveniences are generated), some loving grandchild will pat her precious wrinkled hand, and say, ”Granny, you know, it’s getting to be about that time. Wouldn’t a last wonderful weekend in Vegas be just the thing?”
Ten years ago the Oregon Health Plan demonstrated for the world how not to market assisted suicide services. Now that assisted suicide is finally becoming an option for many more Americans, take that lesson to heart. If you play your cards right this thing can really become big for you.
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