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I would argue that assisted death be considered as an extraordinary act, and that the involvement of hospital social workers, counselors, and even hospice could do much to eliminate this supposed threat. Provision should also be made to legally restrain physicians or anyone else from proposing it as an option to patients. While opponents claim that legalizing assisted death should not even be considered until we have universal health care, this denies the fact that: (1) many patients are currently suffering; (2) plans for universal coverage have been proposed without solution since the early 1970s; (3) both "passive" and active euthanasia in the form of termination of care and "double effect" are widespread without similar concern; and (4) assisted death is widely practiced without any present controls or guidelines. I would argue that this fear could be reduced if any legislation allowing for assisted death also require private and public insurers to guarantee payment for other possible options as well as for end-of-life counseling for the patient and significant others. In the absence of this possibility, other approaches might include tying legislation to public funding for community-based hospice programs or even the drastic act of prohibiting private or public insurers from paying any associated costs of assisted death except for counseling services.
Stepping back for a moment, however, the assumption here is that these populations, for economic reasons, would feel the psychological pressure to choose death over the high cost of end-of-life medical care. This economic argument hasn’t been borne out in studies of other behaviors, such as the relationship between income and either family size or abortion, and it most certainly hasn’t yet been shown to exist in end-of-life decision-making. It’s not as if people would be faced with only the choice of relentless suffering or assisted death. And it's not as if economics is the only factor individuals and families take into consideration in making decisions. Nevertheless, rationing of health care, futility of care, and health care costs are issues that are only now being addressed, and the debate will continue for several years; and I envision that assisted death and termination of care will unavoidably be at the center of these issues.