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Physician-Assisted Suicide Leads to Health Care System Reorganization:
Does Either Socialization or Privatization Provide Equal Access?
Courtney Garroutte
Academic affiliation: Oklahoma State University
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Physician-assisted suicide is a commonly debated topic in the world of moral ethics today. Physician-assisted suicide also brings to light several fundamental problems with two common systems of health care. "Physician-assisted suicide occurs when the physician provides the necessary medical means for the patient to commit suicide, but death is not the direct result of the physician's act" (Bernat 436). Critics of physician-assisted suicide claim there are several unavoidable risks. Opponents state that physician-assisted suicide would: undermine the integrity of the medical profession, create psychological distress of the patient and their families, permit coercion of patients to unwanted use, and allow for physician-assisted suicide to be carried out without the consent of the patient (Brock 522). All of these issues have been managed with the criteria of Oregon's Death With Dignity Act and are avoidable. However, there is one legal argument that remains unanswered by supporters of physician-assisted suicide. Ezekiel Emanuel analyzes the fact that supporters of physician-assisted suicide are often educated, wealthy, white, nonreligious, and under sixty-five years of age. These supporters are a group of society that seem to be protected from the harms of physician-assisted suicide. "They tend to have good health insurance, intact, supportive families, and the social skills and know-how to get what they want from an increasingly bureaucratized health care system. Conversely, the harms of legalization are likely to fall on vulnerable members of our population" (Emanuel 641). Emanuel is implying the benefits of physician-assisted suicide are likely to help the wealthy and insured while the harms are likely to affect the poor and uneducated. This disparity reinforces the inequity in the health care system and our society in general. The unanswered claim, that the harms of physician-assisted suicide are likely to only be experienced by the poor and uninsured, lead many scholars to reject the idea of physician-assisted suicide altogether. Instead of debating about physician-assisted suicide, the debate really needs to advance to the fundamental issue at hand: improving health care for all individuals not just the wealthy.

Most of the debates concerning physician-assisted suicide continue to focus on its moral permissibility to determine it legal status. Ezekiel Emanuel believes that the primary factor in determining physician-assisted suicide's permissibility is the inequity of its potential harms and benefits. Emanuel asserts that the debates are not focusing on the real issue at hand; instead they are distracted by legal propaganda that leads them to invalid assumptions. The assumption that all members of society have equal access to health care is a fundamental flaw that is used to determine physician-assisted suicide's moral permissibility.

Emanuel supports the idea that the health care system must treat all members of society equally before physician-assisted suicide is deemed morally permissible. Without equal distribution of health care, physician-assisted suicide is not morally permissible (Emanuel 641). In the United States, health care is not available to all members of society; forty three million Americans do not have medical insurance (Floyd 235). The moral permissibility of physician-assisted suicide is dependant on the fact that all members of society would be equally affected by its perceived harms and benefits. According to Emanuel physician-assisted suicide is not morally or legally permissible in a health care system that is analogous to that of the United State's because health care is not equally distributed.

Although many Americans believe our health care system is reasonable, poor Americans have very little access to health care services. On the other hand, the wealthy have no limitations to any service they desire; if their insurance does not "cover" a particular procedure, often the can afford to pay for services on their own. These services have no limits and offer the best technology in the world to the wealthy but are seldom an option for the underprivileged. If the poorest members of our society do have access, it is much more likely they will fall prey to its possible harms. In the case of physician-assisted suicide, a wealthy-insured person is more likely to benefit because they usually have: a close long-term relationship with their physician, a supporting intact family, and the ability and knowledge to get what they desire from a bureaucratic health care system. On the other hand, the poorest members of our society are faced with the burden of considering the costs of medical procedures instead of the possible benefits to their health. They must consider the financial ramifications when choosing any medical service including physician-assisted suicide.

Another problem that would be solved with Emanuel's proposed system is the financial burden associated with end-of-life care. Underprivileged families are often concerned with rising costs associated with expensive procedures and treatments and would be more likely to choose physician-assisted suicide because of this financial burden. Poor patients are forced to choose between medical procedures that burden their families financially or physician-assisted suicide that presents no costs at all. This idea makes many scholars take a step back from the physician-assisted suicide debate and consider our inequitable health care system first. It seems that the debate concerning physician-assisted suicide's moral permissibility is missing the point altogether. From an ethical standpoint, most would agree that a choice like the one many poor patients have to make, should not have to be considered in a just health care system. The health care system's biases need to be addressed before physician-assisted suicide is a topic of moral debate.

Many of the debates over physician-assisted suicide assume that all individuals in society would have equal access to medical services but this is rarely the case. The fact that nearly half of the population in the United States is without medical insurance proves the assumption is not a valid and rational one to make. People without medical insurance have limited access to medical services and are often unable to see a physician for weeks at a health department. This situation manufactures impersonal relationships with physicians that the Death With Dignity Act in Oregon forbids. Many scholars believe that it is a necessity to maintain a long-term and personal relationship with the physician that will assist in suicide. This proves to be difficult for the uninsured who seek medical services at health departments where doctors rarely have permanent status.

It seems as though Emanuel is suggesting that the health care system be reorganized so that all members of society are entitled to equal services. Even though Emanuel never directly states "socialized medicine" he alludes to this proposal. This proposed system resembles a system of socialized medicine in several ways. In socialized health care systems all members are entitled to the same services; this would alleviate the problems of unequal distribution. In modern-day socialized systems like Canada's, it is illegal to purchase better insurance. Allowing the wealthy to purchase better health care would also provide superior access to medical services. In an ideal socialized system, physician-assisted suicide would be permitted because many fundamental problems with unequal distribution are intended to be eliminated.

In socialized medicine, procedures and treatments would be paid for by collected taxes therefore this financial burden would be almost nonexistent. In an ideal system, poor families could care for sick family members without worrying about finances. Although socialized medicine seems to be the solution to the discrepancies associated with physician-assisted suicide, it does pose some significant problems. Critics of socialized medicine claim that it lowers the quality of health care. Socialized medical systems depend on the government for funding. Because of the cost of medicine and procedures governments strive for economical systems. Critics claim this creates a system that provides only basic treatments when more evasive measures need to be taken.

Functioning socialized systems tend to stray from the original intentions. There have been instances where patients have been sent home after arriving at the emergency room, when they would have been accepted in unsocialized systems. These cases tend to make critics think that people in need of help are not able to get assistance when it is needed most. Cost effective procedures must be put in place so that current systems stay within their allocated budgets. Physicians in socialized systems believe that money should have no bearing on the procedures their patients require. Some believe that patients deserve only the best care, regardless of cost.

Socialized medicine has many faults that need to be closely examined before it is considered a solution to the problems with physician-assisted suicide. A socialized health care system may provide equal health care to all members of society but not without serious drawbacks. It appears that the idea of solving physician-assisted suicide's problems by introducing a system like socialized medicine, Emanuel is in fact opening the door for an entire different debate.

The American system of health care is often described as "privatized health care", while systems like Canada's are referred to as "socialized". Even though the two systems are fundamentally very different, they both claim to provide the public with the basic health care needs.

Internationally accepted standards set five broad goals for the development of health care systems: availability (are resources adequate to meet the needs and geographic distribution of a population?), accessibility (can individuals gain access to those resources, in an appropriately equitable manner?), acceptability (are patients' culturally specific needs and expectations being met?), quality (are professional and community standards of "good practice" met?), and affordability (can individuals and the community in general meet the costs of the care provided?). (Twigg 2253)

Twigg addresses the fact that it is also widely recognized that these five goals are mutually contradictory (2253). The United States and Canada are primary examples of these internal contradictions. Improvements in the quality of care or providing universal access inexorably lead to increased costs. The ideal health care system would strive for a balance among the five goals, without letting one area fall short.

Canada's socialized system aimed to provide all members of society with health care, while simultaneously letting the quality of service decrease tremendously. Canadians seeking the service of a physician are faced with long waiting lines because the system is in high demand. "In Vancouver, the wait is one to three months for psychiatric, neurological or routine orthopedic opinion; six to nine months for cataract extraction, two to four years for corneal transplantation, and six to eighteen months for admission to a long-term placement bed" (Smith 496). Canadians are not only faced with extensive wait periods, their system also decreases incentives for advancements in medical technology. "Another price the Canadian public has had to pay is the slow introduction and bleak availability of some of the advances in high tech medical advances which US citizens expect to have available. At last count, Canada had a total of 12 nuclear magnetic resonance units in the entire country" (Smith 496). These numbers are miserable in comparison with the United States. A vast majority of American hospitals contain at least one CAT scanner, and more often than not, have access to several machines. Insured Americans have grown accustomed to superior technology and the health it provides but are reluctant to concede to the resulting high cost. However, uninsured Americans that are eligible for Welfare have access to health services from local health departments. It is widely acknowledged that services rendered by health departments are limited and require long wait periods if available. Underprivileged Americans that seek services from local health departments are more familiar with the weaknesses of a health care system like that of Canada's.

America's "privatized" health care system also has problems with providing the five basic needs associated with health care. While we provide advanced medical technology, we fail to provide affordability. This shortcoming has forced employers to pay large sums of money to insurances companies to maintain their employee's insurance policies. Corporations that provide their employees with medical insurance must pay the higher premiums or reduce the coverage of the insurance plans to compensate for the costs of advanced technology. Reduced coverage equates to access to medical services. Insurance plans that once covered dental, eye, and general services are often reduced to provide only general services provided by family physicians. Employees are then left to pay for dental and eye exams out of their own pockets or simply not obtain those services.

It appears as though socialized and privatized health care systems have faults in several areas. The question that remains to be answered is if a "socialized" system could alleviate the problems of inequity the "privatized" American system presents so that services like physician-assisted suicide could be deemed permissible. When examining the situation in Canada it would be appropriate to assume that all members of society, even politicians and celebrities, receive equal care. This assumption is crucial in determining if indeed the "socialized" system provides its principle goal of equal service without discrimination. Although the design of Canada's plan eliminated the inequities between the wealthy and the poor, the functioning system has failed to provide unbiased access. An American physician, Walter Block, addresses this notion in an essay titled "Socialized Medicine is the Problem". Block states that Canadians complain not of long wait lines at doctor's offices, but of the inequality of the system. "Most of the complaints have focused on the unfairness of a system that allows the privileged to receive medical care within a few days of an injury, while forcing others to wait weeks even months, if not years" (Block 467).

In 2002, Canadian basketball player Bryant "Big Country" Reeves hurt his ankle and was catapulted to the head of the medical waiting list. There are several documented cases of hockey players and politicians receiving the same privileges as Reeves (Block 467). These cases of discrimination make one thing clear; "socialized" medicine in Canada is not providing access equally. Instead, self-destruction is inevitable because the system weakened at its strongest point and its primary objective. This failure has caused many to consider a system that combines privatization and socialization. "Recently, Canadian Prime Minister Jean Chrétien changed his mind about his countries system of socialized medicine. After long and hard opposition, he now favors a two-tier health system, including user fees and private provision" (Block 467). Would socialized systems like Canada's fail to be universal in other areas as well? Emanuel proposed a system like Canada's to alleviate the inequities that privatized medicine creates. The proposed system is supposed to be evenly distributed so that physician-assisted suicide and other controversial services would be deemed permissible because all members of society would be equally affected.

It seems evident that the two systems of health care used in the United States and Canada are not without fundamental flaws. The American system provides its patients with the most advanced technology in the world. However, the care received in the United States is very costly. On the other hand, the Canadian system provides all members of society with what some ethicists believe to be a human right, health care. The socialized system is designed to provide universal care but does not allow for advancements in medical technology because there are no incentives. Each system has strengths and weaknesses that compliment each other but seem to be inconsistent on their own.

Emanuel believes that physician-assisted suicide is morally impermissible in a system like the United States where the wealth reap the benefits of a bureaucratized system. Nevertheless, the Canadian socialized system does not take care of the unequal distribution of services. There are many documented cases in which high-profile individuals are given preference and placed above other members of society. Even if the socialized system did not allow high-profile, and usually wealthy, individuals certain privileges; the wealthy could attain the desired services in the United States. Taking all of these aspects into consideration it is hard to prove that socialized medicine alleviates financial inequity, instead the wealthy acquire superior service in the United States.

Despite the problems experienced in Canada and the United States, their systems are deserving of praise. However, government bureaucrats impose rigorous standards and control the health care systems in both countries alike, forcing physicians to ration health care by restricting their patient's access to services. In both systems money is what appears to be the government's final concern instead of society's general health. "Physicians are no longer dedicated independent practitioners, but docile, complaisant employees of the networks that employ them" (Faria 15). When the government is involved in areas of society like health care, standards are imposed that reflect the beliefs of elected leaders and not of health care providers. If health care systems were designed by physicians and concerned with the health of their patients' then society's overall health would benefit tremendously. Procedures and treatments, like physician-assisted suicide, would be allowed only if they were beneficial to the most important element of health care; the patients.

When considering the health care system, one must not jump to conclusions about the "best system". Several considerations must be addressed before deciding on one particular system that would benefit society the most. Although the ideal health care system appears to be flawless on paper, it is hard to determine its effectiveness until society has a chance to point out its weaknesses. In the debates concerning physician-assisted suicide, Ezekiel Emanuel suggests that a socialized health care system would alleviate inequities, when in fact; socialized medicine has the same flaws as privatized medicine. It seems possible that there is no such system that is completely accountable for the alleviating the advantages of wealth in health care.

Works Cited

Batlle, Juan Carlos. "Legal Status of Physician-Assisted Suicide." Journal of American Medicine 289.17 (2003): 2279-2282.

Bernat, James L., Bernard Gert, and R. Peter Mogielnicki. "Patient Refusal of Hydration and Nutrition: An Alternative to Physician-Assisted Suicide or Voluntary Active Euthanasia." Biomedical Ethics. Thomas A. Mappes and David DeGrazia, eds. Boston: McGraw Hill, 2001. 436-442.

Block, Walter. "Socialized Medicine is the Problem." Journal of Surgery and Neurology 60 (2003): 467-468.

Brock, Dan W. "A Critique of Three Objections to Physician-Assisted Suicide." Ethics 109 (1999): 519-547.

Emanuel, Ezekiel J. "What is the Great Benefit of Legalizing Euthanasia of Physician-Assisted Suicide?" Ethics 109.3 (1999): 629-642.

Faria, Miguel A. "Corporate Socialized Medicine Threatens Medical Profession." Human Events 52.31 (1997): 12-18.

Floyd, Elizabeth J. "Healthcare Reform Through Rationing." Journal of Healthcare Management 48.4 (2003): 233-241.

Smith, J P. "The Politics of American Health Care." Journal of Advanced Nursing 15 (1999): 487-497.

Twigg, Judith L. "Health Care Reform in Russia: A Survey of Head Doctors and Insurance Administrators." Social Science & Medicine 55 (2002): 2253-2265.

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