The coronavirus pandemic is forcing us all to make hard decisions. Italy is discovering that it may have too few intensive care units and ventilators for thousands of desperately ill people with breathing difficulties.
So some Italian doctors are arguing that their hospitals should implement a system of triage, or healthcare rationing.
If patients appear too ill to benefit from a ventilator, doctors would let them die so that they can care for patients who have better chance of recovering. Out the window goes the “first in, first served” principle. In a time of “castastrophe medicine”, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care contends that utilitarian principles must be followed.
Utilitarianism must be in the air, because, by a happy coincidence, two Scottish academics say that legalising assisted dying would substantially benefit both those seeking to die early and the public.
Dr David Shaw, of the Universities of Basel and Maastricht, and Professor Alec Morton, of the University of Strathclyde, are by no means shy about their position. They put forward three economic arguments in the journal Clinical Ethics: the cost to terminally-ill patients of a poor quality of life, the cost of care that could be better used elsewhere and potential benefits to organ donation (PDF here).
Dr Shaw, the lead author, says: “Some people might suggest that it is callous to consider assisted dying from the perspective of resource management; these are real people with real lives. This criticism is misplaced. Part of the motivation for our argument is precisely that these are real people with real lives who wish to avoid suffering.
The first argument is that it enables consenting patients to avoid negative “quality-adjusted life years” (QALYs).
QALYs are a measurement of disease burden which encompasses the quality and quantity of life lived which is widely used by health professionals to determine the value of health outcomes.
Second, resources consumed by patients who are denied assisted dying could instead be used to provide additional QALYs for patients elsewhere who wish to continue living and improve their quality of life.
Third – and most disturbing of all — organ donation could provide an additional source of QALYs in this context.
The authors argue that, together, the avoidance of negative QALYs and gain in positive QALYs suggests that legalising assisted dying would substantially benefit both the small population that seeks assisted suicide and the larger general population.
They argue that denying assisted dying is a lose-lose situation for all patients. In the paper the authors write:
“Quality-adjusted life years have been used for decades in healthcare allocation decision-making.
“By combining quality of life and mortality into one metric, they enable quantification of the medical gains and losses and relative financial costs of a vast diversity of treatments and interventions, in turn enabling these different treatments to be compared against each other and funding decisions to be made.
“Organ donation could also benefit because there are several reasons why donation after assisted dying is better from a clinical and economic perspective.
“First, if patients are denied assisted dying, organ function will gradually deteriorate until they die naturally, meaning that transplantation is less likely to be successful. Second, patients who choose assisted dying have to go through a lengthy process, and organ donation can be easily integrated into that process, non-coercively, decreasing the risk that family members will attempt to overrule donation, which often occurs when a patient dies in a way that is not planned.
“The legal arrangements for assisted dying vary widely from country to country, and if the UK was to legalise assisted dying (presumably in the form of assisted suicide) the calculations here could be made more precise based on the specifics of the approach under consideration. Nevertheless, our paper shows in general that denying dying plausibly imposes great costs on both patients who wish to die and those who do not.
“However, our argument is not that legalisation of assisted dying should be primarily based on economic arguments; these are supplemental facts that should not be neglected. Legalising assisted dying in the UK is likely to yield a substantial increase in QALYs across the patient population as a whole.”
Dr Gordon Macdonald, of the British lobby group Care Not Killing, which opposes assisted suicide, said: “This report is highly disturbing. It highlights the dangers of legalising euthanasia. Very quickly the argument moves from that of personal autonomy to doctors and nurses making value judgments about the quality of other people’s lives while seeking to save money and tackle so-called ‘bed blocking’ in health services.”
Inevitably, over the next few months, people will ask if saving the lives of the weak and elderly really is worthwhile. According to an increasingly plausible utilitarian calculus, it’s not, as this article argues so aggressively. The pandemic will reveal whether our societies can walk the walk and not just talk the talk when they swear that they are committed to human dignity.
Michael Cook is editor of MercatorNet