The ominous backdrop of California’s End of Life Option Act

By Norisa Diaz
9 November 2015

The enthusiasm of the Brown administration for the End of Life Option Act is based not solely on the autonomy and compassion the law can grant the terminally ill, but on its cost-saving potential.

California Governor Jerry Brown signed into law last month the California End of Life Option Act (CAELOA), legislation that will allow terminal patients to request a prescription for medication from their doctor to end their life. California is the fifth US state to legalize physician-assisted suicide. California, Oregon, Vermont and Washington have legalized it through legislation, while Montana did so through a 2009 court ruling.

The new law goes into effect January 1, 2016 and is modeled after the Oregon Death with Dignity Act (DWDA). It will benefit many terminally ill patients who will take comfort knowing that they can set the terms of their passing. To access aid-in-dying medication, it requires that a person be terminally ill within six months of death, 18 years-of-age and of sound mind, a California resident, and have a referral from two physicians before the person can request the prescription that must be filled and taken without the assistance of others.

Over the past year, a wave of renewed interest in aid-in-dying bills has expanded from four states in early 2014 to 25 jurisdictions and the District of Columbia introducing similar bills, according to Barbara Combs Lee, president of the death-with-dignity non-profit Compassion & Choices. Lee and most advocates of physician-assisted suicide attribute the renewed interest to the case of Brittany Maynard, a 29-year-old woman diagnosed with an aggressive malignant brain tumor, which caught international public attention.

In November 2014 Maynard became a physician-assisted-suicide advocate upon her terminal diagnosis and relocated from California to Oregon so that she could request aid-in-dying medication. Maynard’s story, along with those of thousands who find themselves in a similar and tremendously difficult position, is heartbreaking and finds sympathy even amongst layers who would not choose physician-assisted suicide for themselves.

A May 2015 Gallup poll showed that 68 percent of Americans supported having a choice to access physician-assisted suicide, and that number was even greater amongst youth at 81 percent. Gallup notes that “strong majorities have supported this for more than 20 years.”

While most agree that they would like to have the choice to choose their passing if they found themselves terminally ill and enduring great pain, the passage of the California law after nearly 25 years of pressure from advocates, and the renewed fight to pass similar ones in many other states, has a material basis to incentivize doctors to promote the “cheaper option” as the health care industry pressures for cost-cutting measures.

After a quarter century of attempts by advocates to pass aid-in-dying legislation in California, the ruling class is piggy backing on the emotionally moving accounts of the terminally ill in the most opportunistic fashion as part of its efforts to cut government-funded health care costs. Many death-with-dignity advocates celebrating the CAELOA have expressed gratitude to Governor Brown for looking “into his heart” to find “compassion” for terminally ill people who would like to choose their passing.

However, the decision by the Democratic California governor has not been made solely out of the goodness of his heart. The astronomical costs of medications already play a role in determining who has access to treatments that might extend life by months or years.

Dr. Leonard Saltz, chief of gastrointestinal oncology at Memorial Sloan Kettering Cancer Center, reported on CBS’s “60 Minutes” that cancer drugs are “priced at well over $100,000 a year. … And remember that many of these drugs, most of them, don’t replace everything else. They get added to it. And if you figure one drug costs $120,000 and the next drug’s not going to cost less, you’re at a quarter-million dollars in drug costs just to get started.”

A 1998 Georgetown University Center for Clinical Bioethics study found a strong link between cost-cutting pressures on physicians and their willingness to write lethal prescriptions for terminally ill patients. The study urged “a sobering degree of caution in legalizing [assisted death] in a medical care environment that is characterized by increasing pressure on physicians to control the cost of care.”

Such instances have come to light in Oregon, including the 2008 case of Barbara Wagner, a 64-year-old woman with a highly aggressive lung cancer. The last hope by her doctors was to try a $4,000/month drug. Her insurance company, however, refused to pay for it and instead offered to cover drugs for a physician-assisted death that cost around $50.

Paul Longmore, professor of history at San Francisco State University and a disability advocate, has stated: “Given the absence of any real choice, death by assisted suicide becomes not an act of personal autonomy, but an act of desperation. It is fictional freedom; it is phony autonomy.”

Californians Against Assisted Suicide (CAAS), a coalition of conservative groups, has led the fight against the new law. CAAS wrote on its web site, “We all know that ‘choice’ is a myth in the context of our unjust health care reality. … End-of-life treatment options are already limited for millions of people—constrained by poverty, disability discrimination, and other obstacles. … Adding this so-called ‘choice’ into our dysfunctional health care system will push people into cheaper lethal options.”

While it is true that many end-of-life decisions are pushed upon families and individuals burdened with massive health care costs and pressures—such as cramped housing and elder care—CAAS argues against the CAEOLA from the right, using language that opportunistically feigns concern for the poor in an effort to cloak its religious disapproval and moral outrage. Many of the groups who make up the coalition are anti-abortion advocates. If free universal health care and endless funding for hospice were available for all, CAAS would still dispute death with dignity on moral grounds.

The new law comes on the heels of the announcement in October by the Social Security Administration that 65 million people will not see a cost-of-living adjustment in their Social Security or SSI disability checks next year. The bipartisan budget deal reached late last month between President Obama and Congressional Republicans cuts Medicare reimbursements to hospitals and other health care providers by another 2 percent across-the-board, increasing the likelihood that providers will refuse to accept Medicare patients, thus shrinking the availability of critical services.

The cost-cutting potential of CAELOA is completely in line with the Affordable Care Act, which has seen out-of-pocket costs for enrollees climb 74 percent since 2013, while punishing and fining those who cannot afford insurance. It is also in line with the Medicare Access and CHIP Reauthorization Act of 2015, passed in April, establishing a new payment system in which doctors will be financially rewarded for cutting Medicare costs and punished for the volume and frequency of the health care services they provide.

The increased cost of health care, the dismantling of employer-sponsored health care, cost-cutting and increases in Medicare and denial of cost-of-living adjustments, no doubt have the potential to push some poor people to opt for aid-in-dying medication.

From every direction, the unions, insurance companies, the Obama administration, corporations and Wall Street send the message to seniors and pensioners that they are living too long and the drugs and procedures that may extend their lives by months or years are not worth the cost.

A socialist program advocates the right of individuals to choose the time and method of their own passing. It also fights for an end to medicine-for-profit and the establishment of free, high-quality state-run health care for all.