My presentation takes issue with the certitude of their conclusion, assesses portability of the Dutch practice to our for-profit context, and suggests some contrasting actions in care for the dying in our contexts.

Emanuel and Battin set out to explore the claims of “enormous cost savings” attributed to the practice of euthanasia or physician-assisted suicide.⁶ They use three factors in their calculation.⁷ They include:

1. the number of patients who would use euthanasia or physician assisted suicide
2. the amount of life that these patients would forgo
3. the end of life health care costs that these patients would have represented

Emanuel and Battin determine the number of patients who would use euthanasia and the amount of life forgone by these patients by extrapolating and applying data from the 1990 Netherlands’s Remmelink Report. An estimated 2.9% (3700) of the total deaths (128,786) were caused by active euthanasia and physician assisted suicide (PAS).⁸ Assuming that the same proportion of patients would choose euthanasia and physician assisted suicide in United States as in the Netherlands, euthanasia and PAS would total 67,000 deaths in this country in 1990. They report that the average amount of life forgone through the use of euthanasia and physician assisted suicide is about 7.2 weeks and therefore use 2 months as the second factor in their equation. Using Medicare data for the cost of care for the last year of life, they calculate that $10,118 is saved if the last month of life is forgone and $14, 508 if the last two months of life are forgone.

Results

Emanuel and Battin apply these factors in their calculation and estimate a cost savings approximating 978 million dollars. They suggest that their estimate is an overestimate for the following six reasons. First, the Netherlands numbers includes patients receiving euthanasia without explicit consent. This practice is not permitted in any of the proposals currently tendered by advocates in the United States. This would reduce the number receiving euthanasia or PAS in our country to 48,517 persons or 2.1 percent. Second, terminal illness as defined as having 6 months or less to live is a required prognosis to access euthanasia according to current United States proposals. Emanuel and Battin estimate that this would reduce the amount of life forgone from 8 weeks to 4.3 weeks. They appear to base this upon hospice data which suggests that most people seeking end-of-life care do so in their last month of life. Factoring this in with the previous adjustment, the cost savings would decrease to approximately 491 million dollars. Third, they suggest that the use of the most expensive treatment group of euthanasia candidates, cancer patients, causes the estimate to be inflated. This is coupled with a fourth reason and that is an estimate based upon conventional care. The authors then suggest that the lower costs of hospice care causes their figure to be overestimated. Fifth, they propose that since some patients are already receiving PAS or euthanasia, there may be an overestimate because of double counting. Finally, additional costs for euthanasia incurred by mandatory second opinions, data evaluation, and litigation may actually add to Medicare expenditure. Emanuel and Battin adjust for some of these variables by multiplying the 2.1% explicit consent group-times-one month of life forgone-times-the cost of hospice service and arrive at a lower figure of 260 million dollars saved.

They consider two other factors which might cause 978 million dollar figure to be an underestimate. In the Netherlands seven percent of the patients ask for euthanasia or physician assisted suicide and yet only 2.1 percent receive the practice. If everyone that asked for euthanasia and PAS received it in the United States, the seven percent figure, the total number of patients using the euthanasia or physician-assisted suicide option might increase to 161,000 persons. Secondly, Medicare expenditures may underestimate the cost of end of life care since there are numerous things that Medicare does not cover in its reimbursement scheme. Emanuel and Battin take the figure of 161,000 and multiply it by triple the conventional Medicare costs ($43,521) for end-of-life during the last two months and arrive at a cost of care savings of 7 billion dollars.

The authors conclude that the lower number, 260 million dollars, to the higher figure, 7 billion dollars, only accounts for 0.01%-0.7% of the United States’ total health care spending. They conclude that this number is minuscule because only a small number of people die each year, less than 1 percent,. Further, of those who die only a small fraction would receive euthanasia or assisted suicide, only 0.029 percent. In the United States 99.97% would still be receiving health care at regular costs demonstrating that “the myth of cost savings through euthanasia is clearly wrong.”

Assessment

Emanuel and Battin’s effort is laudable. They provide the first tangible attempt to consider the possible implications that euthanasia or PAS would have on health care resource consumption and costs in this country. Although laudable this attempt is not without significant difficulties, difficulties which raise doubts about both the precision of their results and certitude of their conclusion.

First, Emanuel and Battin’s suggest that we “forget for the moment the difference in terminology between physician assisted suicide and euthanasia.” Clarity of terminology used in the euthanasia discussion is essential. Define euthanasia by including intent of the medical act, and the set of individuals intentionally terminated becomes broader. This in turn changes the magnitude of costs and potential savings. For instance, Hendin includes the Netherlands’s population who were explicitly and intentionally terminated by the administration of opioids increasing the percentage from 2.9% to 3.7% or another 1350 persons.⁹ In earlier publications, authors such as Henk Ten Have asserted that if the total number of cases where pain medication is used solely or partly for the purpose of hastening death, the final figure for euthanasia in the Netherlands rises the from 2,300 to about 8,100 cases.¹⁰ Further if one includes the withholding or withdrawal of treatment with the purpose solely or partly to hasten death, it would increase the number by another 8,000 cases.¹¹ The point is this, if one clearly defines the practice of euthanasia and PAS broadly as “medicide,” that is, “the application of medical practice for the purpose of intentionally hastening the patient’s death,” then the estimate of 2.9% is clearly low.¹² The number increases to 12.50% (16,500 persons) that experience the practice of “medicide” in the Netherlands. This is clearly higher than their 7% overestimation.

Second, Emanuel and Battin assume that the Netherlands data accounts for all the “medicides” occurring in that country. They overlook the fact that the numbers cited come from 76% of the respondents.¹³ Were there “medicides” performed by the 24% of the non- respondents? This point is open to debate. Hendin asserts that only 18% of the cases of euthanasia were reported to the government in 1990 and those without consent “were virtually never reported.”¹⁴ How many cases of voluntary or involuntary which remain unreported in the 24% of the non-respondents is of course unanswerable. The presence of such cases and their absence in the Emanuel and Battin’s calculation lessens the precision.

Third, Emanuel and Battin assume that the “medicide” rate in the United States will approximate that of the Netherlands. This assumption is questionable. A comparative study between the two countries shows that in 1982-83: 10.8 persons per 100K over 65 in the Netherlands committed suicide versus 18.9 persons per 100K in the United States.¹⁵ The suicide rate in the United States for persons over 65 receiving Medicare, is approximately 57.14% higher than in the Netherlands for the same time period. If we look at the average age of enrollment into hospice, 76.4 years of age, and compare that age group’s suicide rates according to a Washington state study, we see a 42% increase in the rate among the 75+. This brings into question both the inter-cultural portability of suicide comparisons as well as the accuracy of forecasting for future generations.¹⁶

Fourth, Emanuel and Battin’s determination of the amount of life forgone except perhaps for the last week or less, is shear speculation. A two month prognosis as well as the six month category of terminal illness is a guess at best. Further limiting euthanasia or PAS to the category of terminal illness alone misses the point of the ‘right to die’ philosophy. The ‘right’ is associated with a subjective determination of one’s inherent personal dignity and demands a broader framework in which to participant. Even if we do entertain the 6 month restriction, precision would seem to call for a more weighted calculation which factors in the 15% patients outliving their 6 month terminal hospice diagnosis as well as the 16% living less than seven days after hospice admittance.

Finally, these calculations assume the same proportion of people using euthanasia or physician-assisted suicide now as in the future. This assumption neglects a shift in cultural more and acceptability of the practice as boomers age. Further, it does not take into account the economic, social, and allocation implications of the projected bankruptcy of Medicare entitlements projected in 2010. These unknown variables appear to make their declaration of cost savings as “myth” more tentative than certain.

The variability of the three criteria in the formula make an accurate projection of cost savings difficult to determine. The unaccounted for intentional deaths hastened by opiates and forgoing life sustaining treatment can increase the number of deaths from 2.9%(67,000) to 12.50% (289,000). If we adjusting this figure with a 57.14% (562,222) higher suicide rate in the United States and adjust the first figure in their calculation to include the 24% of lack of responding physicians to the survey, we arrive have about 700,000 receiving “medicide.” If we use their average projection of $14,508/2 months life forgone, our calculation yields a cost savings of 10.15 billion dollars.

What then of the notion of the “myth of significant or enormous savings?” Their judgment of a less than 1 percent cost savings significance is made in the context of the total United States health care expenditure. The significance might look different if we consider the amount saved in the context of line item budget cut like that of hospice or home health care within the Medicare/Medicaid budget. If we take the overestimate of 7 billion dollars, it still accounts for only 0.7% of the Medicare budget.¹⁷ In their words this dispels the idea of an “enormous cost savings through assisted suicide or euthanasia.”

It will be recalled that their discussion started out by seeking to find if there was a “significant” or “enormous” cost savings in the context of Medicare. The question remains: “Is the range of savings from 978 million to 10.15 billion dollars “significant”? Although it represents only in their low estimation 0.03% to my adjusted estimation 8.54% of the total Medicare/Medicaid budget, it represents more when we stratify the savings to cancer patients and particularly to the hospice budget. In 1995 the average figure 978 million/1.854 billion dollars represents a savings of 52.75% of the entire hospice funding dispersed. If you use our adjusted figure it represents a savings of over 10 times the money dispersed for hospice payment in 1995.¹⁸ This suggests that in both scenarios the cost savings for euthanasia and PAS or “medicide” may be more significant than Emanuel or Battin first concluded (See table one).

Conclusion

Upon further reflection it appears unlikely that anyone may achieve an accurate prospective calculation due to the lack of factual data in our context, due to contextual differences between the US and the Netherlands, and due to the complexity of variables that effect such a calculation. Even more recent data from the second Dutch commission study does not change claims to precision, rather it adds uncertainty to the unknown variable of increased practice over time.¹⁹ This sword cuts both ways of course since my own estimate suffers from the same defect of speculation. It is not the speculation that raises my concern in this study however. Rather, it is the strength to which the conclusion is asserted. The certitude of the claim that the cost savings of euthanasia is a “myth” appears to be an overstatement when considering the nature of the calculation. This leads me to conclude that the true profits of death have not yet been cast in stone, particularly when considering an even greater variable, the cross-cultural portability of “medicide” from the socialized medical complex of the Netherlands to our “medical-industrial complex.”²⁰

Introduction

The impact of Emanuel and Battin’s euthanasia and PAS calculus on cost savings was constructed without apparent consideration for cross-cultural portability. By this I mean that consideration for differences between “medicide” in the Dutch system of socialized medicine and our system of for-profit medicine were not taken into account. Some Dutch euthanasia proponents suggest that cross-cultural portability of such practices are doubtful because of the special characteristics of the Dutch context.²¹ These include: (1) the national insurance of the majority of the people under their socialized medical system, (2) the high standards in palliative care, and (3) the prevalence of long term patient-physician relationships facilitated through the practice of ‘house doctors.’ The most prominent difference in the two systems, however, is each society’s goal of health care delivery. In the Netherlands the goal is to provide a common and acceptable level of health care for all citizens. Modalities of treatment including “medicide” are in service to that end. In the United States’ medical industrial complex, the telos of health care is to provide the consumer with the level of health care desired for an appropriate profit. Modalities of treatment including proposed “medicide” initiatives are in service to that end. It is this goal of profit that raises both the doubt of cross-cultural portability of practice and the doubt of making a precise economic forecasts using the Dutch model.

The emphasis on profit in the medical industrial complex of the United States not only brings into question the precision of Emanuel and Battin’s calculation but casts a persistent shadow on use of “medicide” as a modality of treatment in the industry’s armament for profitable care. At the outset cost savings seems to be the concern of Emanuel and Battin’s study. Their figures suggest that the meager savings from PAS and euthanasia provides little incentive for the practice or danger of “thrift euthanasia.” In contrast, my adjusted figures make “thrift medicide” far more attractive. Our differences of opinion rests upon speculative calculations and may be resolved when and if the practice is permitted and if it is closely monitored. My concern transcends the disagreement over figures, however. It goes to the instrument of profit, that is money, and its potential to turn the medical industrial complex into a “structure of sin.”²²

Mammon as Master

A Christian appraisal of money reveals nothing new; rather, it repeats the ancient concept of mammon . The term mammon connoted a sacralization of money as part of a material system of power (cf Mt. 6:24). Money becomes the medium by which the powerful, for the sake of self-interest, control the needs of the powerless. It is described by Ellul as having a strange and almost living persona which brings the user under control of its aims.²³ He elaborates saying:

We absolutely must not minimize the parallel Jesus draws between God and Mammon. He is not using a rhetorical figure but pointing out a reality. God as a person and Mammon as a person find themselves in conflict. Jesus describes the relation between us and one or the other the same way: it is a relationship between servant and master. Mammon can be a master the same way God is; that is, Mammon can be a personal master.²⁴

We can, if we must, use money, but it is money that really uses us and makes us servants by bringing us under its law and subordinating us to its aim. We are not talking only about inner life; we are observing our total situation. We are not free to direct the use of money one way or another, for we are in the hands of this controlling power, a mode of being, a form to be used in relating to man -- exactly as governments, kings and dictators are only forms and appearances of another power clearly described in the Bible, political power.²⁵

The Medical-industrial Complex: profit the root characteristic

The medical industrial complex’s use of its abortion sub-industry may provide an apt paradigm of what “medicide” for profit could be. In our current context the aborted human being not only provides patient choice at the cost of human life but also furnishes the cosmetic, bio-tech, and pharmaceutical industries with hormones, nervous system stem cells, and systemic thrombolytics. One might view the extrapolation from abortion to “medicide” a rather long leap. Reputable publications exist which reduce the distance of this leap however. For instance, Fung proposes a policy of “wealth transfer through voluntary death.“³⁰ He recommends the development of an option for the hopelessly ill to choose an early “dignified passage” through euthanasia. The hastened death would preserve and enhance that patient’s estate through converted entitlements from Social Security, Medicare, or perhaps Medicaid. He suggests a policy which would provide a sixty percent incentive payment for an early death.³¹ Additional profit to the deceased estate may be realized through pre-arranged organ donation. He proposes that early death benefits the society as well. The person can perform a final redeeming act for family and country by preserving health care resources which can be re-channeled to the productive members of society. In turn gains preserved through that individual’s sacrifice should be denied to others deemed hopelessly ill or non-participants in order to avoid squandering scarce resources and the individual’s act of courage.³²

What is fascinating about Fung’s proposal is its very existence. The idea is entertained and the initial shock gives way to desensitization. Little, pragmatically or philosophically, leads me to believe that the “medicide” product line will remain unmarketed. The advertising glut of other medical products from hemorrhoid remedies, prostatitis prescriptions, adult incontinence diapers, and abortion counseling in common magazines is a break with the non-marketing approaches of twenty-years prior. Spin the notion to accommodate a final contribution to the benefit of society or to the guilt-ridden individual seeking reconciliation associated with a fragmented relationship, and suicide readily becomes a last act of reified redemption. Philosophically, the varieties of humanistic naturalism upon which much of the “medicide” movement is predicated appeals to rather than deters the swift exit of those who impinge upon the progress of the species or the greater good of all species. In such a world view the choice to disencumber the human species or all species from a high resource consumer appears to be a noble act for either an individual or a society.³³ There seems little in the way of naturalism and particularly our emerging western social Darwinism which lends philosophical warrant for the preservation of the infirmed; rather the noble savage seems most admirable by choosing to exit when no longer productive.

As the ‘boomer’ population ages, demands for health care resources increase, and disparity in access threatens, will the complex succumb to profit motives or economic survival? Will it use ‘thrift medicide’ to secure social or corporate survival or profit? Will the current calls for “emergency contraception” in connection with cost savings to society evolve into future calls for ‘emergency medicide?’³⁴ The answer may well depend upon the governing principle of the complex and what the complex will become. Is it in service to God or mammon, care or capital? Will it be a structure of sin or a community of compassion?

It would be disingenuous to reduce all health care providers to servants of Mammon or characterize Emanuel, Battin, or Fung’s position as a heartless and merciless profit calculation. Although some pro-medicide advocates like Fung emphasize the economic side of health care, he as many demonstrates a pathos common within the medical-industrial complex. As such the “thrift medicide” option is tendered in lieu of “enduring a cold and isolated existence in an alien nursing-home environment or imposing an interminable burden on the patient’s family.”³⁵ This experience is apparently not far removed from what Fung perceives of his mother’s existence as an Alzheimer’s patient.³⁶ His concern for isolation and burden is often heard in “medicide” discussions. It is a concern which is indeed warranted and merits a response, a response which provides contrast through a rupture into the “solitude” of alienation, isolation, and burden.³⁷

Christian communities have often done well to alleviate burdens of the vulnerable. They have made an effort to proclaim and live out Christ’s message of good news by clothing the poor, feeding the hungry, saving the unborn, caring for the infirmed, and bridging social chasms of racial diversity. An old chasm, however, obstructs our life sojourn in a different place because of the change in the way die. We would do well to hear the voices of consternation of those on the edge of this precipice, for their demand to a right to “medicide” expresses the cry of “inter-estedness” solitude.³⁸ It discloses the voice of one seeking an escape from ‘being’ reduced to a merely medical mortal.

Their cry calls us to re-think how we live and die in community. This entails retrieving a theology of martyrdom. Muted by the drone modernity’s machine, we need to reformulate the meaning of our death in a voice that can be understood both individually and corporately. Deep contemplation of death as a witness to Christ and a ministry to community must be once again “emerged” to consciousness.³⁹ Dying involves some sense of suffering. It does not mean that we seek suffering but that physical, emotional, and spiritual suffering must be seen in possible contexts of repentance, sanctification, ministry, and in the end ‘facing’ the unmerited loving-saving presence of God.⁴⁰ Sproul provides insight into this imaging, suggesting that suffering and death need not be a surprise to the Christian or anyone else for that matter.⁴¹ They are indeed our inheritance from the Fall. But beyond this, suffering provides ruptures into our existence where God’s glory can be manifested. Manifestation might be in healing as seen with the blind man of John 9. It may be for spiritual sanctification as it was for Job. It may be for the sake of a witness of Christ’s presence to others as in the case of Paul (Phil. 1:19-26). In all these instances living through dying becomes a witness to a merciful God who is there. The outworking must be retrieved in living and dying as a thoughtful being in community.

These lessons, life’s praxis, and their results break through personal or communal isolation however. The community of faith is called upon to respond to those in affliction as “said” in passages like Mat. 25 and James 5:13-18.⁴² The community needs to revive a sacramental theology of anointing where the afflicted and her ministers covenant their inter-relationship and life before the Lord. For the community anointing signifies the enabling of the afflicted to live their season of adversity incarnating Christ Jesus as a witness of hope to the unbelieving who teeter or will soon teeter on the same precipice. Community ‘facing Jesus’ through mercy, kindness, and charity serves as a deeper witness and testimony to His Spirit’s sufficiency and presence. Such ‘facing’ may be manifest in that believing community’s provision of respite care for the patient’s family, providing transportation, yard maintenance, volunteering in hospice care, financial contributions, and bereavement support for the family. For the dying person anointing affirms a covenantal relationship. Through the power of the Holy Spirit and the help of the community, the relationship reflects a witness of the hope to all who cling to Jesus Christ for safe passage beyond the confines of death’s deep chasm. Dying is a time of sequestering that which God has granted person and community from narrative past to a life now and life transcending this mortal veil.

The community of faith must continue to assert and modify approaches to medical care so as to serve the isolated and minimize their burden. In so doing and so being the Christian community must heed the call to reconstruct the structures and practice of Judeo-Christian Hippocratic medicine wherever and whenever it can. It must do so as both an incarnational and contrast community. By incarnational I mean one which through the regeneration and outworking of the Spirit of Christ it serves the faceless, disenfranchised, weak, and powerless. It is a call to service which re-integrates health care into the household of faith to which special attention is foremost (Gal. 6:7-10). It, also is a call to live out the virtue of the Good Samaritan, who rendered mercy and justice as a neighbor to the suffering faceless one along the Jericho Road. Pragmatically, it is a call for the continued development of Christian community-based health care. This service should utilize existing structures, transforming them when it can from “structures of sin” into structures of mercy.

By “contrast” I mean a call to provide an alternative when these structures are absent or hostile to the transformation or expression of God’s agapeic love. Concretely, the Christian community is called to better understand what needs of the dying are not being met by hospice, hospitals, long term care, and health care professionals. From this selected sites will be determined as places for appropriate pilot programs in diverse communities. The result desired is the development and continuation of caring communities equipped to respond to those who are dying in and outside the believing community. It is a horizon of being where the dying person can transcend the faceless figure of profit and ‘face’ the prophetic figure of Christ in a community of contrast to hopeless and dying world.

Jerome R. Wernow Ph.D., R.Ph.
Northwest Center for Bioethics, Consulting Director

Please note that Drs. Emanuel and Battin intend on publishing their revised study in the near future. The text was not available for consideration at the time of the submission of my text. I would like to express my appreciation to Dr. Margaret Battin for her review and critique of the first portion of this work.

Table One Estimated Cost Savings for Cancer Patients

%US patients treatment type Conventional Care: 8 weeks($14,508) Hospice Care:4 weeks($5,413) Hospice Care:tripled Explicit request 2.1% (48,800) - ~$260 million - Explicit & non-explicit requests 2.9%(67,000) ~$978 million - - All requests 7.0%(161,000) - - $7 billion Medicide:all intentional terminations 30.0%(700,000) $10.15 billion $3.78 billion -

¹ I am using Kevorkian’s sense of the term “medicide” in order to limit the agent and the act of assisting in death to the application of medical practice. In this case medicide means the ‘the application of medical practice with the intent of hastening a patient’s death.’ cf. Kevorkian, Jack: Prescription Medicide: the goodness of planned death. (Prometheus: Buffalo, N.Y., 1991) p. 202. Kevorkian writes: I propose that the term “euthanasia” be restricted to denote the termination of life by anybody. If performed only by professional medical personnel (such as a doctor, nurse, paramedic, physician’s assistant or medical technologist) then it becomes medicide.
² Sulmasy, Daniel: “Managed Care and Managed Death,” Archives of Internal Medicine. (January 23, 1995) p. 135. Dr. Sulmasy is director of the Clinical Center for Bioethics at Georgetown University.
³ My presentation considers information delivered by Dr. Margaret Battin’s address to the Third World Congress of Biothics, November 1996. She and Dr. Emanuel have subsequently submitted an article based upon this address for publication. The article uses new information from the second ‘Remmelink Report.’ They have kindly provided this work to me, however, due to publication issues I was not permitted to cite information from this document Although the figures changed, the formulas, principles, and conclusions are representative of the 3rd World Congress presentation.
⁴ Hayry, Heta and Hayry, Matti: “Euthanasia, Ethics, and Economics,” Bioethics, (Summer, 1990) v.4/2, pp. 154-161. The authors allude to “thrift euthanasia” in the context of economics and possible financial incentives.
⁵ Emanuel, Ezechiel and Battin, Margaret: “Potential Cost Savings in Legalizing Physician-Assisted Suicide,” from the Third World Congress of Bioethics. (San Francisco, November 20, 1996) tape #106-F.
⁶ Emanuel and Battin expressed a preference for the use the term ‘ euthanasia or physician-assisted suicide ’ rather than the broader term “medicide” to describe the act of an intentional hastening of a patient’s death. Their term is more specific and will be used to reflect their intended limitations. “Medicide” will only be used in the broader sense described previously.
⁷ Emanuel and Battin: op. cit.
⁸ Maas, P.J. van der; J.J.M van Delden and L. Pijnenborg: Euthanasia and other Medical Decisions Concerning the End of Life. (Elsevier: Amsterdam, 1992) v. 2, p. 186.
⁹Hendin, Herbert; Rutenfrans, Chris and Zylicz, Zbigniuew: “Physician-Assisted Suicide and Euthanasia in the Netherlands, Lessons from the Dutch,” Journal of the American Medical Association. (June 4, 1997) v. 277/21, p. 1720.
¹⁰ten Have, Henk A.M.J. and Welie, Jos V.M.: “Euthanasia: Normal Medical Practice?” Hastings Center Report (March-April, 1992) p. 35.
¹¹IBID., p. 36.
¹²Kevorkian: op. cit.
¹³Hendin, et al: op.cit., p. 1720.
¹⁴IBID., p. 1721. The existence of these cases seem clear since the Remmelink Report reveals 1030 cases medicides without consent.
¹⁵The Statistical Abstract of the United States 1982-1983. cf. WWW.Trinity.Edu/~mkearl/death.html#di
¹⁶Youth Suicide An "Increasing Problem" MMWR 1997; v. 46, pp. 502-506. Further study must be done to compare the 1990 figures to determine both if the international difference still persists and if there is an increase suicide rate amongst the group receiving Medicare.
¹⁷cf. http://www.hcfa.gov/stats/hstats96/blustat2.htmTable 30-Medicare/type of benefit which is equivalemt to 1.854 billion dollars or 1.6% of Medicare expenses.
¹⁸For the year of 1995 cf. http://www.hcfa.gov/stats/hstats96/blustat2.htmTable 30-Medicare/type of benefit which is equivalemt to 1.854 billion dollars or 1.6% of Medicare expenses.
¹⁹Hendin, et al: op. cit. p. 1721. They conclude that euthanasia deaths have increased from the 1990 to the 1995 study by 20%-40%.
²⁰The “medical-industrial complex” has been described as the rapid development of the current health care system in the United States from private community health care providers into a large complex of inter-related commercial corporations. Although there are differing opinions in regard to the potential good or evil of such a complex most agree that the newly emerging health care delivery system has one primary characteristic by which it evaluates its raision d’ etre, profit. cf. Relman, Arnold S.: “The Health Care Industry: Where is it Taking Us? The New England Journal of Medicine. (September 19, 1991) v. 325/12, p. 854. He states: Referring to what I called the “new medical-industrial complex,” I described a huge new industry that was supplying health care services for profit. It included proprietary hospitals and nursing homes, diagnostic laboratories, home care and emergency room services, renal hemodialysis units, and a wide variety of other services that had been formerly been provided largely by public or private not--for-profit community-based institutions or by private physicians and their office. cf. also Engelhart, H. Tristram and Rie, Michael A.: “Morality for the Medical-Industrial Complex: A Code of Ethics for the Mass Marketing of Health Care,” New England Journal of Medicine. (Oct. 20, 1988) v. 319/16 pp. 1086-1089.
²¹cf. www.netlink.co.uk/users/vess/dutch.html: Euthanasia in Holland. The author of the site states: Many researchers, in the Netherlands and abroad, have drawn attention to the specific characteristics of Dutch culture and suggested that countries need to find their own solutions rather than simply try to import the Dutch system wholesale. Two of the three reasons given include: (1) There is a high standard of medical care - amongst the highest in the world. The majority (over 95%) of people are covered by private medical insurance, guaranteeing a large core of basic healthcare, including long-term care. (2) the relationship of trust between doctors and patients, to a much higher level than in most other countries. Moreover, most patients know their doctor well, and over a considerable time period.
²²Pope John Paul II: “Encyclical on Social Concerns,” Origins (trans. Sollicitudo Socialis Rei; March 26, 1987, section 36-37) (March 3, 1988) v. 17/38, pp. 353-354.
²³Ellul, Jacques: Money & Power, translated by David W. Gill. (Downers Grove,IL: Inter-Varsity Press, 1984) pp. 75-76. Power is something that acts by itself, is capable of moving other things, is autonomous (or claims to be), is law unto itself, and presents itself as an active agent. This is its first characteristic. Its second is that power has a spiritual value. It is not only of the material world, although this is where it acts. It has spiritual meaning and direction. Power is never neutral. It is oriented; it also orients people. Finally, power is more or less personal. And just as death often appears in the Bible as a personal force, so here with money.
²⁴IBID.
²⁵ IBID.
²⁶I am using the ‘face’ in a similar yet different sense disclosed by Emmanuel Levinas. The ‘face’ transcends phenomenon by “saying” and by saying it calls the listener to respond. My use differs from Levinas in that the ‘face’ of the suffering servant ‘reflects’ the ‘face’ of Christ and this facing calls for the response of the other ‘not to euthanize’ but rather ‘to feed, to clothe, to take the stranger in’. As the ‘face’ of the dying one reflects her Savior’s suffering so also does it reflect her Savior’s call to righteousness and call to judgment. This ‘face’ is as Levinas uncovers when saying In the access to the face there is an access to the idea of God. cf. Levinas, Emmanuel: Ethics and Infinity. translated by Richard A. Cohen from Ethique et Infini (Duquesne University Press: Pittsburgh, 1985) pp. 85-92. cf. also Mat. 25: 31-46.
²⁷Pope Jon Paul II: op. cit.
²⁸IBID.
²⁹IBID. Common obstacles to the common good of the people resurrected by such structures were said to include (1) an a domineering and rigid ideology, (2) a fragmentation of human solidarity and interdependence, (3) an oppression of Christian faith in moral decision making, and (4) a source for other sins.
³⁰ Fung, K.K.: “Wealth Transfer through Voluntary Death,” Journal of Health and Social Policy, v. (5) 2, 1993, pp. 77-86.
³¹ IBID., pp. 78-79.
³² IBID., pp. 77, 83-84.
³³For a critique of the superiority of the human race cf. Singer, Peter A.: Rethinking Life and Death: The Collapse of Our Traditional Ethics. (New York: St. Martin’s Griffin, 1996) pp. 165-175.
³⁴Reuters Medical News: “Emergency Contraception: A "Public Health Gem," July 12, 1997. or cf. James Trussell et al: Am J Public Health 1997; 87: pp. 909-910, 932-937. Reuters summarizes their conclusions stating that Emergency contraception, including contraceptive pills, progestin minipills and the copper-T intrauterine device, can reduce the substantial medical and social costs associated with unwanted pregnancies.
³⁵op. cit. p. 78. Fung views the alternative to his position as one of: enduring a cold and isolated existence in an alien nursing-home environment or imposing an interminable burden on his children’s family.
³⁶IBID. Fung dedicates his article to his mother stating that she believed that : a good death is as important as a good life but whose Alzheimer’s disease prevents her from having a dignified exit.
³⁷Levinas: op. cit., pp. 57-59. Levinas describes solitude as an isolation of an individual’s private existence, her own being. He recoils from the impersonal notion of Heideggarian being where one dies alone. Solitude makes this isolated existence and “marks being” and despair from which the dying seeks to escape. This notion can often be personally ‘signed’ by a visit to a generic nursing home.
³⁸ IBID., p. 52. “Inter-estedness” is used in contrast to Levinas’ notion of “dis-inter-estededness” where the patient is reduced only to the frame of reference of another person’s subjective interpretation of them.
³⁹By the use of emergence I appeal to an emergent property view of mental states. An explanation is beyond the scope of this work but has much in common with the depth psychology of Viktor Frankl.
⁴⁰Levinas: op. cit.
⁴¹Sproul, RC Jr. (ed): “Unwarranted Surprise,” Tabl
⁴²talk. (July 1997) pp. 25-26.

cf. footnote 26 and the notion of “saying.”