DOLLARS AND DEATH; IN ERA OF HMOS, BOTTOM-LINE ECONOMICS MAY BE DRIVING FORCE BEHIND ASSISTED SUICIDE MOVEMENT.

Byline: Marta Russell

LIVING in a neoliberal era, where the interests of business dominate government and public policy and in a climate that more and more measures one's worth by economic efficiency, demands that we scrutinize the ``right'' to die beyond a liberalist expansion of individual rights. We must look at the timing of these policy proposals.

Why assisted suicide now, with the increase of mysterious viruses and incurable illnesses like chronic fatigue, AIDS and fibromylagia, which require costly drugs and long-term care? Why now, with managed care corporations rationing health care, and with public health care under the budget ax?

In his latest book, ``Freedom to Die - People, Politics and the Right-to-Die Movement,'' Derek Humphrey, co-founder of the Hemlock Society, the oldest and largest pro-euthanasia and assisted suicide group in the United States, says that it will be the unspoken argument for assisted suicide - cost containment - that will ensure the eventual passage of laws legalizing assisted suicide and euthanasia.

Humphrey argues it will not be the drive for increased autonomy (as the death with dignity slogans assure the public) but the drive to save health care dollars that will push public policy in their direction. Humphrey is right to make the connection.

But some have been openly and unabashedly speaking the unspoken for several years now.

The convicted murderer Jack Kevorkian exposed his real agenda when he wrote in a written statement to court (Aug. 17, 1990) ``The voluntary self-elimination of individuals and mortally diseased or crippled lives taken collectively can only enhance preservation of public health and welfare.''

Courts are listening to this line of reasoning. When the 9th Circuit Court in San Francisco ruled that individuals have a constitutional right to physician-assisted suicide, it specifically targeted the handicapped as ``beneficiaries'' when it stated that it may be acceptable for ``competent, terminally ill adults to take the economic welfare of their families and loved ones into consideration'' when deciding whether to live or die, and defended the use of assisted suicide to control medical costs.

An editorial in the Weekly Standard, a voice of the GOP majority, concluded in 1995, ``Sick people are expensive. The dead are a burden to no one. Years ago the child had whooping cough and died. Now that child grows up to be a very expensive old man or woman. The only answer is some kind of rationing, Gingrich knows that.''

This gives cause to ask what is really happening when Kevorkian and others talk about voluntary self-elimination. Are people who seek assisted suicide choosing death or being cornered into it by inadequate national disability policy, a lack of long-term and palliative care that, in their absence, makes life so unbearable that death seems preferable to life?

Oregon, a state which legalized assisted suicide, made changes to its Medicaid policy so that the state will prioritize payment for physician-assisted suicide since federal laws prohibit funding. Physicians there have reported that the state also restricted funding for a key pain medicine, Oxycontin, making this needed treatment virtually unavailable to many chronically or terminally ill patients so that effective doses were not available to patients with diseases like amyotrophic lateral sclerosis (Lou Gehrig's disease), diabetic neuropathy, multiple sclerosis, reflex sympathetic dystrophy, and a host of painful, disabling, or fatal disorders.

Disability advocates have reported that there are difficulties in obtaining the hours of attendant services needed to remain at home in Oregon.

Surveys have consistently found that most people would rather continue to live at home rather than in a nursing home. What has not been known until recently, however, is that the aversion to nursing homes is so strong that a new study of seriously ill people in hospitals found that 30 percent of those surveyed said they would rather die than live forevermore in a nursing home.

Research on those who have elected to die under the new law reveals that people did so over concerns about loss of autonomy or loss of control of bodily functions - fears which are not being addressed by uniform public policy like quality in home care and psychological support services to ease the transition to disablement.

Instead, Humphrey's answer and increasingly that of more assisted suicide advocates is to give elderly and disabled people the freedom to kill themselves rather than to demand a national attendant services (PAS) program be put in place that would enable elderly and disabled people to remain in their homes rather than be warehoused in institutions.

In the Managed Care Era, it is essential to ask, will people choosing death be the victims of a health care system that is more oriented toward reaping Wall Street dividends rather than relieving pain and depression, providing comfort at the end of life - care which is costly to health corporation and state budget bottom lines?

With the advent of managed care, there has been a payment paradigm shift. In the name of containing costs, HMO hospitals and doctors no longer get paid for individual services rendered, they get paid a flat fee. This shift means that those needing the most health care are no longer perceived as an asset (bringing more money in) they are seen as a liability (draining the profits).

Furthermore, managed care corporations manipulate fees to control gatekeeper physicians' approval of expenditures on patients; doctors are given bonuses for keeping costs low and often find their contracts revoked when they do not conform to HMO administrators' directives.

Dr. Linda Peeno, a physician who found herself in such a predicament, testified before the House Commerce Committee in 1996, ``I wish to begin by making a public confession. In the spring of 1987, as a physician, I caused the death of a man.

``Although this was known to many people, I have not been taken before any court of law or called to account for this in any professional or public forum. In fact, just the opposite occurred: I was `rewarded' for this. It brought me an improved reputation in my job, and contributed to my advancement afterward. Not only did I demonstrate I could do what was expected of me, I exemplified the `good' company doctor: I saved a half-million dollars!''

Is all this not sufficient evidence to conclude that there is a direct link between physician-assisted suicide and efforts to reduce health-care spending on poor, sick, and disabled people? The issue of physician-assisted suicide must be viewed within the context of an economic order that is eviscerating the social contract by encouraging government to retreat from its responsibilities to the public's welfare.

Will the public now in support of assisted suicide hear the unspoken?