11 Comments
Apr 18Liked by Eric Mathison

I too found his discussion of incentives in health care somewhat lacking. The neglected part is that the "cost" of the health care is actually a source of revenue for the people and organizations that are mostly delivering health care. The incentive for the actors in the system (doctors, hospitals, drug companies), where there is one, is actually to deliver as much health care as possible, long past the point where the patient wants it or stands to benefit.

The groups who stand to benefit from reducing costs (e.g. government/taxpayers in Canada, insurance companies in the US) are often actually those with the least ability to alter individual patient behaviour. It is weird to me that so many discussions of MAiD amount to "yes I agree it should be available, but it should be really bureaucratic and complicated so we can make sure that fewer people get it".

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There's quite a bit of evidence to support the argument that clinicians are influenced by advertising, gifts, visits from pharmaceutical representatives, etc. Clinicians will choose the more expensive, less good thing for their patients under these influences. However, I'm not sure there's any evidence to suggest that clinicians, on a patient-by-patient basis, make decisions to steward healthcare resources, e.g., "Wow. Healthcare costs are out of control. I'm going to order the cheaper medicine for this patient today." This is why, I think, there's so much discussion around system-level controls to mitigate healthcare costs (from policies and formularies to nudges within electronic medical records).

I doubt it would play well to see an organization, whether private or governmental, to make a policy obviously favoring assisted suicide/euthanasia (ASE) over any medical intervention.

However, I imagine two avenues of perverse *disincentive*:

1. If there is a population of people that present a bedeviling problem to the healthcare system - maybe their care requires a lot of time, money, or resources - and many or most of them avail themselves of ASE. Insofar as there's an impetus to provide these resources, that impetus becomes less forceful or urgent when more people die before pressing their needs upon the system. How could you prove that this is a perverse disincentive? It would manifest as a negative; a lack of societal, political will to improve conditions. Now, healthcare the world over appears like a wicked problem even before the introduction of ASE, so I don't think you could establish to what degree it degrades the political will to improve the system, but I doubt it can make it better.

2. Most people live by default. They're not waking up every day choosing not to kill themselves. When they're offered death, they can choose to live or choose to die, but one thing they can no longer do is live by default. The mere offer of the choice imposes upon them the task of weighing living vs. dying. They'll need to justify their choice to live (if only to themselves), something they may not have done before. This is quite a burden to foist on someone who is already vulnerable. I call this a perverse disincentive because it may subtly dissuade a patient from longevity-focused healthcare when they fail to justify their continued to living to themselves (e.g., Hardwig's "duty to die"). I'll say, in my neck of the woods, this is particularly potent as many people report they "do not want to be a burden to their loved ones."

The challenge of a starkly preference-based view ("It's what they want") is that fails to acknowledge that it's our culture that taught people the content of these beliefs (e.g., about perceived burdensomeness), and their choices will go in to make the culture in which we live. It's hard to establish how any given choice or policy will change a culture at some point in the future. But given what we know about the influence of perceived burdensomeness on "classic" suicidal ideation (e.g., in depression), these considerations should give us pause when considering perverse disincentives.

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Good points. I think burdensomeness is nuanced. In Texas, I had patients tell me they would rather die a bit sooner than drain their savings on treatments that would extend their lives only a little bit. They wanted their family to get the money instead. Patients in Canada have likewise said they don't want to use resources when others could benefit more. In other contexts, these are laudable views, and I think it's fine if patients have them, though this isn't the same as saying that we should encourage people to make these types of choices. But there are also negative forms of burdensomeness, and it can be difficult in some cases to figure out which type we're talking about.

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Unfortunately, I am disappointed. This literally takes "no evidence" and runs with it. I'll just leave these two links here for why this is suspicious at best.

https://www.astralcodexten.com/p/the-phrase-no-evidence-is-a-red-flag

https://thezvi.wordpress.com/2021/12/20/law-of-no-evidence/

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Smith's claim is that there's evidence of perverse incentives. My claim is that the evidence isn't strong enough to support his conclusions and that there are better explanations. I don't say he say no evidence for his views. He might be right, but since there are other explanations, we shouldn't leap from "people might be using MAID to save money" to "people are definitely using MAID to save money". The burden of proof is on the people who claim that the government is using MAID to save money to support their view. I don't see it.

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Judging by Smith’s use of emotive language whenever he’s posted about MAID I think he mainly has a personal distaste for it that he then makes a go at rationalizing from an economics perspective. In my opinion the real divide here is moral rather than technical.

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(The "I can make more money literally any other way", the only part in your post that touches on existence rather than materialization, is an off-the-beat estimate by a medical worker, which I'm disinclined to believe over an economist.)

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No, Smith's claim is that there are perverse incentives, period, because they are there by sheer economic calculation. I think you're conflating the question of whether incentives exist and of whether they materialize - i.e. lead to different outcomes (I have a slight incentive to eat ice-cream only, but it doesn't materialize because I have many overriding incentives).

And in the question of whether the incentives that are bound to exist _materialize_, the burden of proof is on someone who claims that they don't. Same reason why we register conflicts of interest.

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It's both. He claims that there are perverse incentives for providers to push MAID, which I argue is false since they don't benefit. I also argue that they don't materialize, but I grant that they exist when I say that the government could use MAID to save money. My claim there is that there isn't evidence for this any more than there's a perverse incentive for other aspects of healthcare.

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There is perverse incentive for many aspects of healthcare. But if you, say, decide to put someone in palliative care, bound to die in a year, and half a year later, a new treatment is found, it can be tried (remember your oncologist "that's why they close the coffin" piece? There are _reasons_ for them doing this, and not just sunk cost fallacy); if you put someone under MAiD, the same scenario cannot materialize.

Usually, more irreversible measures tend to also be more costly, which mitigates the issue; it is plainly not true of MAiD.

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The same can be said for if one chooses to wait for that half a year later, tries the new treatment and has worse outcomes as a result of it. That has plagued the world of mental health where folks go through the merry go round of treatments with the hope that one will one day finally work while living with all the side effects or suboptimal ways of living. I think the true cost saving measure, is that we, the human race, will one day die. 100% of us. Whether through MAiD or otherwise.

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