Euthanasia and bargaining power within the family

Let’s say more of the world moves to a Netherlands-style euthanasia law.  While euthanasia is at first based on individual consent, it usually evolves into a “in unclear cases your spouse or guardian has the actual say.”

How will this affect bargaining power within the family?  Here are a few options:

1. Family members will be much nicer to each other, ex ante, so they will be kept around for longer if they come down sick.

1b. Because of time consistency problems, family members won’t be much nicer with each other.

1c. You fear that family members aren’t willing enough to pull the plug on you, so you become actively less nice.

2. Family members will be much more anxious with each other, because they will so often be wondering how the others will wish to dispose of them, and when.

3. Some family members will make explicit ex ante deals, such as: “You can send me to my doom when the time comes, with a clear conscience, but on Tuesday nights we’re going to watch my game shows, not your reality TV.”

4. “It stresses me out that you are stressed out over my dying, so I will apply for euthanasia right here and now, even though I still have nine months to live with my cancer.  Except I will tell you that I just don’t want to live any longer, so you don’t feel bad about why I am doing this.”

5. You have no family and given your illness you are a net revenue drain on your nursing home.  If you go back to live out your final days, you’ll end up with the worst room and less spicy food and no private TV.  You agree to euthanasia, granted that they send $20,000 to your favorite charity.  You leave this earth with a warm glow, feeling that 20k probably saved at least one life.  In reality, with p = 0.68 it subsidized someone’s overhead.

What else?

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So far it appears that the relatives are happiest if they can farm the decision out to the doctors. They may want Grandma put down but they are unwilling to say so too openly. On the other hand they may not ask too many questions if the doctor gives Grandma a hot shot. At least that is my understanding of what is going on in the Low Countries.

The obvious effect will be a weakening of family ties. Why invest in your family if they can reasonably be expected to have you killed? When you retire take an annuity not a lump sum. Don't have children at all. Don't kiss and make up. You are individuals who happen to share the same surname name. More or less. No more.

This came up with the death of Terri Schiavo. Traditionally husband and wife were together until death did they apart. Marriage ties were expected to be strong. That was probably never really the case, but today when half of all marriages end in divorce, the husband (speaking in general and not specifically of Mr Schiavo) is likely not to be the best guardian of his brain-dead wife. The parents are likely to be more concerned about her well being. Especially as they do not stand to benefit financially. However if the parents and children can be expected to have a hostile relationship involving one side putting the other side down, that may not be true either.

What we will get is likely to be the government making budget-related decisions. The old are expensive and they do not earn a great deal. So doctors will be encouraged to kill them. Families will not have to make the decision themselves, enabling them to pretend to be warm and close, but they will not protest either.

Yes, Tyler's analysis badly misses the point.

Where the government provides healthcare, these "end of life" decisions will inevitably be made by the government and the cost/benefit analysis will be made from the government's point of view. Although efforts are made to make it appear as though spouses and other family members are making the decisions this is just for PR purposes. When the decision runs counter to the best interest of the State, family members will be regarded as incompetent or conflicted (as, indeed, they frequently are). According to the National Health Service, Alfie Evans' parents made the wrong decision as to whether he should die and so they lost their decision-making role.

'these "end of life" decisions will inevitably be made by the government'

So, how does that work in the U.S., with people who are in prison with a sentence that is lifelong?

'Although efforts are made to make it appear as though spouses and other family members are making the decisions this is just for PR purposes.'

In the case of such American prisoners, one can be fairly certain that is not the case.

'When the decision runs counter to the best interest of the State, family members will be regarded as incompetent or conflicted'

In the case of those prisoners, that is not the case.

This is not theoretical, after all. The various prison systems in the U.S. have been in charge of end of life care for prisoners for a long time. Maybe somebody should explore how various prison authorities handle such cases before making such confident assertions about what the state will and will not do.

Let's see if I can follow this - Prior doesn't want to talk about the issue at hand and so he is going to try to talk about the prison system instead?

Outstanding. Especially as he seems to be praising the quality of the American prison system

You don't even read comments. So, here are the first two lines of what prompted you to write -

''these "end of life" decisions will inevitably be made by the government'

So, how does that work in the U.S., with people who are in prison with a sentence that is lifelong?'

The final line was 'Maybe somebody should explore how various prison authorities handle such cases before making such confident assertions about what the state will and will not do.'

How this is not talking about the issue at hand, as a response to the bmcburney comment, is undoubtedly clear to you.

But let me make it explicit - governments have been making end of life decisions for those in their custody for decades. If you are aware of a trend where American prisoners sentenced to life in prison are simply being handled according to a cost/benefit analysis being made from the government's point of view, please let us know.

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clockwork,

If you have evidence that the Federal or State prison systems permit family members a significant say in euthanasia and other "end of life" decisions (beyond PR "lip service"), you should present that evidence.

I think you misunderstood - the prison system does not allow family members any say, essentially.

And yet, American prisoners at the end of their lives do not seem to be merely disposed of in a fashion that indicates the government is attempting to reduce its costs as the only goal.

So in other words it is legal domestic violence.

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Indeed, I did misunderstand you. I think you may have misunderstood you as well.

So we agree that families have no meaningful say in the "end of life" care provided to prisoners but you contend that "end of life" care received by prisoners is nevertheless indistinguishable from the care received by non-prisoners in similar situations. I doubt this is really true but I am glad the matter has been cleared up. I am looking forward to the evidence you are about to provide in support of your position.

This is astonishingly trivial.

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'but you contend that "end of life" care received by prisoners is nevertheless indistinguishable from the care received by non-prisoners in similar situations'

No, I am saying that no one has ever accused the American prison system of casually ending the lives of the many prisoners in its care due to a cost/benefit analysis. In other words, in a context where many voters would have likely little problem with euthanasia, no one is claiming that the government is engaging in it.

I am open to claims otherwise, of course.

......... I don't think the American prison system is particularly well known for their outstanding care of prisoners, but this is a useless comparison either way. In the absence of legal and norm acceptance of euthanasia, the cost/benefit analysis skews heavily to minimizing the risk of wrongfu death lawsuits.

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This is happening in a more benign way here, apparently. When we updated our wills recently, the lawyer said doctors have been talking straight to very sick people and their families, explaining the likely long-term prospects. Fewer people are opting for heroic measures against certain death, and more people are being made comfortable by hospice care as they approach the end of their natural lives. At least I hope this is so.

So another way to put that would be that doctors have been told by the government to bully the sick and their relatives into agreeing to ending their lives cheaply?

Do you think that the government wants those doctors to discuss the full range of treatments available, especially the expensive ones? If a really expensive and intrusive treatment has some chance of success, do you think the government wants those doctors to talk up the chances of success or talk them down?

'Do you think that the government wants those doctors to discuss the full range of treatments available, especially the expensive ones?'

Is it actually possible you are unaware of the fact that everyone dies, regardless of the full range of treatments?

Sooooo ..... you're totally OK with the government deciding some lives are worth less than other lives and sending those people up the chimney?

Not wait. You just needed to post something, right?

You really have absolutely no experience in this area, do you?

Everyone dies. Decisions are made at the end of life, which for many (some of us will die immediately, of course) is an inevitable reality that remains unavoidable. One hopes that the best decisions are made by those involved, of course. However, there is no single decision, nor a single decision making framework, that covers this subject. What one person may consider compassionate another may consider cruel.

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clockwork,

"Is it actually possible you are unaware of the fact that everyone dies, regardless of the full range of treatments?"

Not only is this very unlikely but nothing in SMFS' comment supports the suggestion.

SMFS' point (as I take it) is that some medical treatments are very expensive and are unlikely to succeed. If you believe prisoners are especially likely to receive such treatments, you should identify the evidence which supports your belief. To me, it seems unlikely.

Read all of his comments.

Admittedly, the range of comments over time makes following them difficult, at best.

And my original point remains the response to your original comment - that in a context where the American government could engage in euthanasia unlikely to disturb a significant number of Americans, it apparently does not do so.

This has nothing to do with the level of care provided to prisoners, per se, apart from showing that it is provided.

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The US government already does pay for most end of life care, via Medicare and Medicaid-- and so far the government has not usurped the role of families in this area.

The government likely spends more than most families would or could if in fact the check had to be written. imho of course.

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'it usually evolves into a “in unclear cases your spouse or guardian has the actual say.”'

Welcome to the real world, at least in terms of a hospital setting (or a trusted personal physician), where the option to increase the morphine dose to 'relieve pain' until respiration ceases is fairly common practice, world wide, without a Netherlands-style euthanasia law.

But you left out the very first application under that 2002 Netherlands law (though possibly in Belgium, and I cannot find a link of this being reported in English language media, nor a German link) - taking a vacation. Basically, a couple no longer wanted to deal with the care giving, and applied for a bed ridden parent so as to be able to take a holiday.

Brevity is the soul of wit. The UK's NHS recently provided the universal, two-word answer for these debates, "Alfie Evans."

In the New York, US, we have legal documents: health care proxies. And, there is the concept of "do not resuscitate." The warden and I are working on that with a lawyer.

Actually, what happens in the UK is irrelevant both in the U.S., where I have personal experience in such (for an aware adult) decision making in the past, and Germany, where what happened to Alfie Evans would not be allowed, due to German history being reflected in German laws.

Such attempts to somehow make a tragic case universal, when it most certainly is not, remain intriguing.

Thank you for the clarification.

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'The UK's NHS recently provided the universal, two-word answer for these debates, "Alfie Evans."' The English NHS decided nothing: the English courts decided. The right of those courts to interfere between father and child was established in the 17th century.

Almost everything I've seen on this case that's been written by Americans has been characterised by hysteria, ignorance, arrogance, and (sometimes) dishonesty. If you know of a sober, intelligent, accurate American account I'd be glad of a link.

You are being obtuse. The NHS set the policy and fought in court to enforce it. The court just ruled that they were allowed to.

Don't be so bloody ignorant. The "policy" is in the Child Care Act.

There is nothing in the act requiring that NHS to hold the kid hostage preventing the parents from seeking care elsewhere.

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Ergo, in the 18th century, Americans decided to break ties with British organized brigandage.

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I don't think I'd put 'relieve pain' in scare quotes.

For opiates do relieve pain, and, they are also a central nervous system depressant. And therefore the dose that adequately relieves pain in the dying can also be expected to shorten life somewhat as well.

Adequate pain relief at the end of life vs. a few more hours or days of life is a tradeoff that raises few if any ethical problems.

There remains a reasonably bright line between offering adequate pain relief and deliberately increasing the morphine drip until respiration ceases.

Amen ti this. I authorized narcotics for my father in the final hours of his life. He was obviously suffering and incapable of making his own decision at that point. The medical staff warned me that the drugs could suppress respiration, but the thought of leaving him in pain (and with just hours or at most a day to live) was unconscionable. I would make the same decision for him again, and would hope someone would do that for me in the same circumstances.

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'I don't think I'd put 'relieve pain' in scare quotes. '

The point is not to relieve pain in such an offer, it is to cause respiration to cease. That is the point about the ever increasing dose - in a small amount of time, a point I did not include.

'that adequately relieves pain in the dying can also be expected to shorten life somewhat as well'

You are correct - the dosage and its continual increase is the way to know what is actually going on. It is one of the uncommented parts of all these euthanasia debates - this is an extremely common and very well accepted part of medical practice (at least among a significant number of doctors, though certainly not all), and its basic purpose is not pain relief, but death.

A complex subject, of course, but if the morphine dose is being doubled every 2 or 4 hours, until there is no living patient to administer the next increased dose to, the point was not really pain relief. At least not of the variety you are referring to.

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1. Is our real fear of our family or of the government? Surely power to pull the plug – especially in polities with single-payer public healthcare – will shift to the state.

5. Less spicy food sounds like a bonus not a punishment. But, again, this is a scenario of the state incentivizing death. What moral shift is necessary for this view to become palatable to the public?

6. How will this affect the share price of Soylent, green or otherwise?

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As Rene Girard said, euthanasia laws make everything that they are supposed to simplify more complicated.

Is the objection to euthanasia or to codifying the rules?

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6. Economists bored with economic questions will continue to make raids on other disciplines, revealing themselves to have minds unsuitable for much other than chess.

Good.

I propose one edit. Make it read "Economists bored with politicizing economic questions . . . " I was about to type "getting wrong." I'm feeling charitable.

The UST 10-year is a 3.029% - sell.

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1. Family members will be much nicer to each other, ex ante, so they will be kept around for longer if they come down sick.

But family relations will be asymmetric. You can kill your child in the womb but it is still a crime to kill them much after birth. On the other hand your child can pretty much have you killed any time he likes. Sure, there is some paper work to take care of and your objections to ignore, but no matter how nice you are to him, he does not have to be nice back.

1b. Because of time consistency problems, family members won’t be much nicer with each other.

This is more likely. Perhaps the only defense against your child killing you is a long record - on paper - of hostility between the two of you. He can't pose as a loving son if there are police records.

1c. You fear that family members aren’t willing enough to pull the plug on you, so you become actively less nice.

I don't think this is a big problem. Especially as these laws will come with a voluntary clause. Anyone together enough to deliberately annoy their children is together enough to ask a doctor to kill them.

2. Family members will be much more anxious with each other, because they will so often be wondering how the others will wish to dispose of them, and when.

Indeed. Best to strike first.

3. Some family members will make explicit ex ante deals, such as: “You can send me to my doom when the time comes, with a clear conscience, but on Tuesday nights we’re going to watch my game shows, not your reality TV.”

Again you have the problem of asymmetry. Parents have to pay now for a return in the future. The child can take the payment - a loving childhood and whatever else - and then renege on his side of the deal. In fact he would be stupid not to.

4. “It stresses me out that you are stressed out over my dying, so I will apply for euthanasia right here and now, even though I still have nine months to live with my cancer. Except I will tell you that I just don’t want to live any longer, so you don’t feel bad about why I am doing this.”

Not very convincing I have to say.

5. You have no family and given your illness you are a net revenue drain on your nursing home.

You can think of the money you saved for Nancy Pelosi as you go.

Pathetic post.

Not a single instance of 'leftist'.

Must do better!

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I suppose you have already factored in the overall income effect here, which dominates most of these substitution effects, and that's not the crux of this discussion?

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"What else?"

None of that, because most people don't think that far out, or in those terms, and it's a good thing, too, as it would make decent family life largely impossible. (If your family life seems a bit too much like dickering over scares resources, you're doing it wrong.)

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More explicitly: grandma will know that she is eating into the inheritance and will feel an unspoken pressure to do the right thing.

This has always been the best objection to Euthanasia laws, and proponents have no answer to it, because it is true.

'grandma will know that she is eating into the inheritance'

Understandable that you don't live in Germany with such a name, but this is does not apply to any significant extent in a place like Germany or the Netherlands.

Because German and Dutch older people live on air! And never need any sort of help at home.

In Germany, it is called Pflegeversicherung, and older people are provided meals, home care, etc. as required, according to their Pflegestufe.

Here is an introduction from Wikipedia - 'In January 1995, the government of Helmut Kohl introduced the Social Law XI 1, the German long term care insurance. It is an independent part of the social security in Germany, in the Sozialgesetzbuch and provides financial provision for the risk of care necessity. Long-term care insurance was introduced as the fifth pillar of social insurance after health insurance, industrial injuries, pensions and unemployment insurance. This fifth pillar is financed by the care fund, which was built for all the individual health insurances.

Insurance is also provided for people who need care because of the severity of their long-term care. Old and sick people are no longer dependent on social security if in need of care. Statutory care insurance covers a portion of the home and residential care costs if an increased need for nursing or household assistance of at least six months is required. This will help the patient i to lead an independent and self-determined life.' https://en.wikipedia.org/wiki/Long-term_care_insurance_in_Germany

It is true that an older person does not live from the state precisely - for example, clothes will still need to be bought out of a person's own funds. However, one could hope we would agree that eating and clothing are not part of 'eating into the inheritance' within the framework of this discussion, whereas long term care is.

Statutory care insurance covers a portion of the home and residential care costs

Depends on the Pflegestufe - maybe you should read this part? https://en.wikipedia.org/wiki/Long-term_care_insurance_in_Germany#The_benefit

For example, this -
Care level I: a need for assistance for at least 90 min per day with basic care needs of at least 45 min per day.
Care level II: a need for assistance must be at least 180 min per day with basic care needs of at least 120 min per day.
Care level III: a need for assistance is required for at least 300 min per day with basic care needs of at least 240 min per day.
Case of hardship: the care fund can provide more services in line with care benefits and inpatient care

Or this -

Inpatient care includes an accommodation in a home. This means that services are provided for the duration of care. The need for inpatient care is assumed. The care fund pays a fee to the nursing home. In care level I, the amount is €1023; in level II, €1,279; and in level III, €1,432. In extreme cases, up to €1,688 can be paid.

Obviously, anyone is free to pay more than that. And as most people in this case already have pensions, that 'portion' seems fairly understandable in context, if one reads further. (Yes, the prose is pretty turgid).

So to clarify, you claimed the State paid for everything and now you are admitting that it does not.

German and Dutch pensioners may be better able to pass on some money to their relatives, but there is no way to guarantee that they will. As the State only pays a portion. Having taken a lifetime of taxation from people, making sure they have less to pass on anyway.

I claimed that older people in Germany did not live on air, that since 1995, there is Pflegeversicherung to cover care needs.

Is Pflegeversicherung a blank check? Of course not. I suspect you would be outraged if it was, though.

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"...this is does not apply to any significant extent in a place like Germany or the Netherlands."

Because most have no estate? They live on a state-supported guaranteed income and pension and never accumulate any net worth.

Not exactly, but it is true that if you earn 200,000 euros a year (for example), the state expects you to make a contribution to the care of your parents, as you clearly are able to provide for them in a way that someone earning 20,000 euros a year cannot.

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What is to answer? Spending huge sums of money on extending life a short time, while making that time objectively miserable is the usual outcome of non-hospice EoL care. It seems that almost any alternative would be an improvement. I think the biggest gain from euthanasia laws would be changing the norm that length of Life alone merits consideration in eol medical decisions. Certainly quality of life and cost of care are valid concerns as well.

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Yeah. Most people don't even save for retirement, never mind adequately weighing their own imminent mortality when making life decision. The whole exercise is a bit pointless in a world where billions of people do things like smoke cigarettes and buy lottery tickets.

Plus, being a euthanasia candidate but unable to make your own care decision is a relatively rare situation (the prevalence of dementia is about 20% even among the oldest age groups, and many people don't lie that long, obviously). And if someone is concerned about this and wants to take action to address it, it seems like it would almost always be solved with a living will.

A living will should narrow down the possibilities of misunderstanding but does it? A simple ban is simple. A living will less so. Most of us are probably afraid of being a vegetable and unable to move while being kept alive by tubes. Fair enough. We might well make a living will to say that an unbearable life should be ended. But who is to judge what is unbearable? A living will cannot be specific enough to deal with every possibility. What it does do is open up what you want to interpretation by others. For instance:

http://www.dailymail.co.uk/news/article-4166098/Female-Dutch-doctor-drugged-patient-s-coffee.html

However the doctor was of the opinion that the woman's circumstances made it clear that the time was now right.

The doctor secretly placed a soporific in her coffee to calm her, and then had started to give her a lethal injection.

Yet while injecting the woman she woke up, and fought the doctor. The paperwork showed that the only way the doctor could complete the injection was by getting family members to help restrain her.

It also revealed that the patient said several times 'I don't want to die' in the days before she was put to death, and that the doctor had not spoken to her about what was planned because she did not want to cause unnecessary extra distress. She also did not tell her about what was in her coffee as it was also likely to cause further disruptions to the planned euthanasia process.

All a bit "this way to the showers gentleman" for my liking. But apparently legal in the Netherlands.

It's true that it is impossible to articulate preferences in advance for every medical situation, but advance directives unequivocally make it easier not harder, because they at least provide some guidance, rather than leaving family and doctors guessing, which is usually the case. The default, when nobody knows what the patient wanted is always the most drawn out and expensive death possible. Some things are very basic (i.e. you can tell them that if you are unconscious and only being kept alive through IV nutrition, to stop all feeding and provide narcotics for comfort).

No euthanasia is simpler than euthanasia. Because when you remove a clear line and replace it with complex legal documentation, you have problems of interpretation and enforcement. What does "unbearable" mean?

A living will may make things easier but only if it is operating within a simple legal and medical framework. If it states the conditions under which treatment is to be withheld for instance. But value judgements are hard.

'No euthanasia is simpler than euthanasia.'

That is not your decision to make when someone decides to refuse a feeding tube.

That is not euthanasia. However if someone makes a feeble gesture that is interpreted as a refusal, in a system with euthanasia, the doctors can pretty much kill at will.

"That is not euthanasia."

Yes it is. People need food to live. Withholding it when they have no ability to feed themselves is effectively killing them.

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An example of lawyers getting involved in health matters can be seen here.
http://www.bbc.co.uk/news/health-43898972
Also see
https://www.youtube.com/watch?v=FGpDRZSB7Tk

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'We might well make a living will to say that an unbearable life should be ended. But who is to judge what is unbearable?'

Clearly, the person that wrote the living will. That was not a trick question, was it?

'A living will cannot be specific enough to deal with every possibility.'

Of course it cannot cover every possibility. An American living will has pretty much precisely zero legal effect in Malaysia, for example. But a living will that says no feeding tube covers pretty much all situations involving a feeding tube.

And you do know that your Daily Mail example has precisely nothing to do with a living will, right? If anything, that article demonstrates the importance of such a document - 'In the latest controversial incident the unnamed woman, who was over 80, reportedly suffered from dementia and had earlier expressed a desire for euthanasia when she deemed that 'the time was right'. Clearly, she did not deem the time right, and the family and doctor ignored her.

'But apparently legal in the Netherlands.'

Not precisely, as the article also points out - 'The Review Committee concluded that the doctor 'has crossed the line' by giving her the first sleeping medicine, and also should have stopped when the woman resisted.

The paperwork and the recommendations of the committee are now being considered by prosecutors and health officials.' Though it is true that there are no plans to punish this doctor, the idea being that a court case would establish where the lines that should not be crossed are, legally.

Actually it has everything to do with a living will. The patient was killed because she had expressed a view about what to do with her if her condition became unbearable.

As it turned out the doctor did not believe her when she said her condition was not unbearable.

What the Dutch Courts are saying is that this is illegal on paper. But they have no intention of enforcing the law or punishing this doctor so it is legal in fact. A doctor can drug a patient so she won't struggle and then have her held down while she is killed. Over the patients frequent and strongly expressed objections.

'The patient was killed because she had expressed a view about what to do with her if her condition became unbearable.'

Even when the text from the article you cite is repeated in a comment, you just ignore it, don't you?

'What the Dutch Courts are saying is that this is illegal on paper.'

Actually, according to your article, the case has not been brought to a Dutch court.

'A doctor can drug a patient so she won't struggle and then have her held down while she is killed.'

You are glossing over the fact that the people holding her down was her family, not some state paid 'shower attendants.'

If it comforts you any, I find this case appalling, though clearly the doctor was working according to the family's wishes, to the extent they participated instead of objecting. That the doctor and the family ignored the woman's wishes is beyond dispute.

I am not glossing over anything. I do not find the fact that this woman's family held her down as she struggled, despite being drugged, while the doctor killed her as mitigating in any way. In fact I find it even more like a horror film than if it had been a Sonderkommando.

I glossed over nothing. This woman had expressed a preference to die earlier on. At the time she expressed a strong desire to live. The doctor chose to ignore her strongly stated view she wanted to live in order to kill in accordance with her previous - and perhaps light hearted - comment about dying when things were unbearable.

'This woman had expressed a preference to die earlier on'

From the article, as highlighted in the comment - 'earlier expressed a desire for euthanasia when she deemed that 'the time was right''

'accordance with her previous - and perhaps light hearted - comment about dying when things were unbearable.'

You continue to completely misunderstand what the woman said, though hopefully not after the third time reading it.

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Why is it filed (also) under Television? Is it because of "no private TV" or because of the game shows versus reality shows dilemma?

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The beauty of a private TV is presumably that you can keep it switched off.

This is not a trivial matter, at all.

Last time I visited someone in a hospital, their roommate was completely passed out with the TV on absolutely full blast. It was deafening, and prevented normal conversation, never mind rest.

This was one of those tiny TVs that you can swing over on a moveable arm so it's 12 inches in front of your face, so you couldn't really just stroll over and turn it off.

Brutal.

Thank you for explaining my comment to me.

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What else?

You can feel and see all, but can't communicate. Your family keeps you alive, suffering great pain, at social security (or insurance) expenses, during many years, in revenge for not been a nice parent.

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«it usually evolves into a “in unclear cases your spouse or guardian has the actual say.”»

Citation needed.

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My wife told me about two euthanasia cases related to her work environment.

The first was the old mother of a colleague with lung cancer after a life of smoking. Euthanasia was not on the radar of any family member until a year before it.

The other case was the father of one of my wife's students with a degenerative nervous condition. He decided to die before becoming a plant. In this case, the euthanasia idea came up 6 months before the effective death.

I know, two anecdotes are not data. But at least points that the decision on euthanasia could also be taken by mentally able individuals while Tyler seems to think only about brain-dead people connected to a breathing machine. It would be great to know how frequent are both cases.

Other thing learnt from the anecdotes is that people don't think that much about euthanasia until it is a realistic alternative. So, the bargaining power may change among family members but a few months before death. Anyway, when people is so close to death rational concerns take the back seat.

Options 1 to 4 are concerns for the people that requires prenups, the rest of people thinks about euthanasia only when needed. Therefore, no changes in family dynamics.

People only talk to a lawyer when they want out of a marriage. But the threat of divorce hangs over every marriage. That is why the manosphere calls it Marriage 2.0. It is not marriage like it was.

Euthanasia will be the same. It will color every human relationship. Even if no one talks about it. It is enough to know the children can.

Why would it color any relationship whatsoever? If someone doesn't ever want euthanasia under any circumstance they can state so in a living will. They can also state under what circumstances they do wish it. They can also name their most trusted person in the world as their power of attorney to decide for cases that are unclear (doesn't need to be a spouse or child).

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Woody Allan on life (from the opening monologue in Annie Hall): it's "full of loneliness and misery and suffering and unhappiness, and it's all over much too quickly."

Allan on suicide (from Play it Again, Sam):
Allan: What are you doing Saturday night?
Woman: Committing suicide.
Allan: What about Friday night?

Of course, the promise of Christianity is conquering death. And all it takes is faith, faith in Jesus, not good works, not being kind to widows and orphans, not even being faithful to one's spouse, just faith. Is suicide an unforgivable sin? Suicide is mentioned only six times in the whole Bible, but when it is mentioned there is no moral evaluation given as to whether it is right or wrong: 1. Abimelech (Judg. 9:50–57); 2. Samson (Judg. 16:28–30); 3. Saul (1 Sam. 31:1–6; 2 Sam. 1:1–15; 1 Chron. 10:1–13); 4. Ahithophel (2 Sam. 17:23); 5. Zimri (1 Kings 16:18–19); and 6. Judas Iscariot (Matt. 27:5; Acts 1:18–20). In fact, the clear and consistent message of the Christian Bible is the complete and full forgiveness of sins (past, present, and future—known sin and unknown sin) through faith in Jesus.

Euthanasia is distinguished from suicide by the complicity of others in the event, and Cowen's blog post implies that the others will be motivated by less than noble (economic) reasons. Cowen doesn't mention the absence of health insurance coverage, or the absence of income as the result of being too sick to work, both draining family resources and often putting the sick person and her family at the mercy of others, especially in the case of someone with a chronic illness. Contrary to what most people seem to believe, most illnesses are not episodic but chronic, from heart disease to cancer to diabetes to renal disease to old age. As chronic illnesses make up an increasing share of illness and medical advancements add to both medical costs and life expectancy for those with chronic illnesses, suicide and euthanasia will become an appealing option for a growing number of people. The unspoken alternative is to guarantee care (medical and comfort) for those with chronic illnesses without draining the resources and the spirit of the family. By not guaranteeing care, everyone is complicit, in particular those who successfully oppose the guarantee.

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Government-funded euthanasia is already here. There is a reason Medicare pays 100% of hospice costs. The family is given a day or two to say good-bye, then the patient is placed into a chemical coma until death. Hospices paid 100% by Medicare are factories of death accoutremented with mournful acaapella choirs and massages for the caregivers, while the patients are efficiently removed from the public dole.

'There is a reason Medicare pays 100% of hospice costs. The family is given a day or two to say good-bye, then the patient is placed into a chemical coma until death.'

You really have zero idea of what you are talking about, do you?

That was my experience watching a parent die in a hospice last year. So, >0

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Government-funded euthanasia is already here. There is a reason Medicare pays 100% of hospice costs. The family is given a day or two to say good-bye, then the patient is placed into a chemical coma until death. Hospices paid 100% by Medicare are factories of death accoutremented with mournful acaapella choirs and massages for the caregivers, while the patients are efficiently removed from the public dole.

You're talking out of your ass.

I wept when I was told that my parent was eligible for 100% Medicare-funded hospice. I shit you not, I was at the end of my rope. I was immensley grateful. In addition, she'd had a terrible, long ride to the bottom with dementia. Her being murdered by the state was best for her and her children. That being said, it went far South of "palliative" care.

This is much more complex than the abortion debate. Abortion is simple murder for birth control + endless paragraphs of garbage words.

Euthenasia of the costly and uninteresting elderly is more of a slippery slope. I felt the very convenient moral blur, the range of rationalizations.

The factories do their work because of grown children like me. Let's just be up front about what's being done.

I'm glad for hospice, which kills people with just enough bells and whistles.

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Have American hospices become death camps? Sad, but unsurprising.

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No, that's now how it works.

We put one family member in with dementia in hospice when the alternative would have been feeding tubes, which the person had explicitly declined when she was competent.

We currently have another, also with dementia, who has been in hospice for about 4 months (since the last trip to the ER), and are in the process of clarifying that she will be able to stay under hospice protocols when the initial 6 months is up.

In the first case, we had a Medical Directive, but no Health Care Power of Attorney (a potentially huge mistake). Fortunately, we had agreement within the family.

In the second case, we have both, so there is clear decision making authority.

Our experience with hospice has been good. We should have put the first person above in hospice earlier, but we were ignorant about how it worked. It would have avoided a final, useless hospitalization.

In writing directions for my own Advanced Medical Directive, I've tried specifically to request that hospice protocols (basically comfort management only) become effective at the time of an initial diagnosis with dementia; I'm looking for a way out at that point. I don't see a legal path to request assisted suicide.

Spend a little while (it won't take long) in a Memory Care facility, or caring for a dementia patient yourself. Its a horrible way to go.

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It is America's nature. I can not imagine death camls in Brazil.

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If you think hospice provides euthanasia services you are presumbaly from an alternate universe farm far away.

...or a freeloading customer

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Vaguely interesting but baggy, like much of your recent economics-related opining.

As long as your mulling old people, euthanasia, and resource allocation, perhaps you should think about this:

https://www.ocregister.com/2016/08/12/the-100k-club-public-retirees-with-pensions-over-100000-are-a-growing-group/

Where are the incentives? Solve for the equilibrium.

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"What Else?"
The Colosseum.
That's what else.

The economic incentives as stated above don't capture the long term implications of not having a bright line between 'allowing someone to die' and 'killing someone.' For that, history and wisdom encoded in religion is a better guide.

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I highly doubt that familial relations will change all that much. We have trouble getting people to do obvious things that will make their lives much nicer decades from now (e.g. eating vegetables, not smoking, having children after being married); very few people are going to invest differently over decades in their family out of things that will not affect them until the very end.

What is already happening is that euthanasia will hollow out palliative care. It is grueling work and the sense of mission has begun to collapse in the Netherlands and Canada (e.g. "I don't want to be a euthanasia waiting room"). With fewer physicians and others working in palliative care this will push more people toward euthanasia.

As euthanasia becomes more widespread, there will be fewer and fewer resources for those who are approaching death and need medical help to keep life bearable. This in turn will make it much harder for family members to spend their final months at home. Those who are amendable to euthanasia will be more likely to take it, but it also means that those who are not will almost certainly end up in high cost situations sooner. Hospice, a major source of comfort and cost control, may well collapse in time with euthanasia.

It is quite likely that euthanasia will spark the worst of both worlds - no cost savings (due to a small number of people who flip from family care to institutional care), more suffering (due to fewer palliative care specialists), and less experienced autonomy (people feeling compelled to take euthanasia due to poor pain control, financial concerns, and the like).

Euthanasia is another one of those things where it barely harms intelligent individuals with ample assets and good social capital. It will almost certainly hollow palliative care for the lower classes and make end of life terrible for those who lack money and strong social ties. But the latter set of people are not influential or powerful so they will be sacrificed yet again on the altar of allowing the rich to maintain their illusions of control.

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"In reality, with p = 0.68 it subsidized someone’s overhead."

A little throwaway comment that suggests someone was recently hit with a reality stick. Recently there was an article shared by a friend on facebook about how the Republicans were dead wrong about welfare not helping the poor (though that wasn't really the claim), that the poor are living better because of welfare. Of course it was correct, but my comment was 'at what cost' . The recipients got 40 cents on the dollar. Apparently the new number is 32 cents.

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Highly speculative and unconvincing. The alternative to legal euthanasia is either forcing people to live with suffering, or force people to take their own lives in messy and humiliating ways. The best argument for euthanasia is also the simplest: It is my own life to lead, and I should decide when/how it ends. Some common sense regulation would prevent the kinds of abuses that Cowen and others worry about.

My thoughts on suicide more broadly:

https://thegooddeath183256296.wordpress.com/.

Not this specious crap, again.

First we have actual evidence. Oregon legalized assisted suicide about two decades ago. Since that time Oregon has been a national leader in suicide exclusive of those assisted by physicians. Far from having fewer people taking their own lives in "messy and humiliating ways", more have done so. Likewise with the Netherlands, we continue to see an increase in suicides and those done in "messy and humiliating ways".

Next up that alternative is not to live with suffering. The vast bulk of patients who seek legalized suicide are not suffering in the conventional sense of the term. Less than half cite either pain or side effects from pain medications. The most commonly cited things (in order) are: loss of autonomy, decreased enjoyment of life, feeling weak or tired, fears about future quality of life, and feeling weak or tired. All of these are things which we can routinely improve - autonomy is greatly improved with better care, decreased enjoyment can be improved with both drugs and better care. Fears about future quality of life is something that psychiatrists are routinely trained to help with. Being tired, well heck I have seen cancer patients on amphetamines because again we can do something.

So beyond the fact that, no this is not some false dichotomy between a glorious death and unmitigatable suffering the safegaurds of which you speak are laughable. The entire Groningen protocol was a completely extralegal set of "guidelines" that directed euthanasia in direct contravention to Dutch law. In every single jurisdiction that has adopted euthanasia we have had multiple instances of physicians who directly ignored "safeguards". Have to have two doctors sign off on a terminal diagnosis? Keep trying till you qualify by finding two doctors willing to falsify diagnoses (as has happened). Not of sound mental status to make this decision? Heck doctors have just injected without getting ANY consent from the patient previously. Physically attempt to stop the doctor from euthanizing is not enough.

Beyond that we have seen euthanasia lead to a hollowing out of palliative care. This does cause real suffering rather some existential crisis about "loss of autonomy". So no your vapid analysis is utterly divorced from reality.

But what if facts and data were actually on your side? This logic is still specious. After all if made rape legal it should reduce the number of rapists who only rape in messy and humiliating ways. Banning something, anything, results in those circumventing the ban doing worse versions of the activity. At some point that is worthwhile trade off. Ban prostitution and you get pimps and assault, declare a free for all and you get increased human trafficking; arguably the data shows that the Swedish model (banning purchase of sex) has the least net harm.

To date I have seen precisely zero data that suggests that euthanasia diminishes actual suffering. I have seen data that suggests people go through with it out of cost concerns, out of obligation, and out of fear. I have seen it result in diminished services for those who wish to live. Euthanasia is a solution in search of a problem.

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Haven't you ever heard of a living will or an advance directive? These already exist right now. This isn't that complicated.

Agreed. How will it affect bargaining power? Zero for the non paranoid.

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One of the primary factors concerning intra-family relationships is the presence or lack of money. Who has it and who wants it?

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All of these are mere luxury problems compared to not having the right to choose when you wish you were dead.

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I feel like Futurama has explored this adequately.

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Tyler is posing a sociological problem, and attempting to analyze it without context, data, or empirical observation.
For example, it presumes the answer will be the same for Japan as it is for America, the same for religious as secular, rich as poor, and so on.

So as posed, it is an abstracted exercise to express our own moral intuitions, biases, fears and suppositions.

"the same for religious as secular": as you imply the religious will presumably wish to expedite their parents meeting their maker.

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Our feelings about old age in general is that we don't think our kids have good judgement so my wife and I agree that we need to take good care of ourselves so we don't need them. This is another logical possibility.

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If your concern is that end-of-life decisions might affect family relations, that ship has sailed because all of these issues are implicated by advanced directives and health care proxies. There is a significant literature on this topic that is more informative than off-the-cuff spit-balling. Maybe so some research.

If your concern is specific to the phenomenon of euthanasia decisions "migrating" to spouses, health care proxies, or next of kin, the easy legislative fix (or private bio-ethical fix) is to make the right to euthanasia personal and prohibit others from exercising that right on their behalf (at least without an express and specific pre-authorization form the patient).

" the easy legislative fix (or private bio-ethical fix) is to make the right to euthanasia personal and prohibit others from exercising that right on their behalf (at least without an express and specific pre-authorization form the patient)."

These "fix" already exists in all legislations about active euthanasia

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the dutch program has experienced mission creep over the years. started out mostly for end stage cancer or degenerative neurological disease.
euthanasia has more recently been used for depression and alcoholism and pretty sure even a victim of sex assault
the numbers have jumped up quite a bit in the last few years particularly for psychiatric diseases including dementia where informed consent is iffy. have the dutch gotten more or less empathetic over the last 15 years ?

Assisted suicide is a very different beast than non-voluntary euthanasia; most of the cases described in the OP are about non-voluntary euthanasia when someone cannot be asked for their consent.

Assisted suicide is morally trivial as suicide is consensual. The "assistance" part is often just writing a prescription, which the suicidal person only needs because free sale of the effective substances is banned by law. If they weren't banned, people could just buy them as normal commodities and end their own lives at their own discretion.

This may also shift relationships, but it is a far cry from "other people make the decision in my stead".

There is nothing more insulting or hostile than being told that your life and indeed pain is not voluntary, even after you explicitly disagree as a well-articulated philosophical statement.

There are actually a lot of things more insulting and hostile than pointing out that the dutch metric for unbearable suffering has shifted from end stage cancer to depression.
Pretty sure the assisted suicide laws
In Oregon and colorado do not apply to depression.

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Are we assuming the same bargaining power is not exerted with a patient in a nursing home or hospice? When someone is given a poor diagnosis there is a certain renogotiation within the family unilt. My mother took the reins when my father became ill. He felt a burden when he could no longer hold a spoon to eat breakfast or walk to the bathroom. The week before he passed my father no longer recognized us and he became very combative. My mother was right when she said, "You're father would never want you girls to see him like this." Dignity would have been allowing him to pass peacefully.

I view euthanasia, abortion, capital punishment, and other personal choices of life and death to be outside the dominion of the state. After fighting for five years my father should have been given the choice to end his suffering. A mother faced with poor choices should be able to end the life within her. A prisoner's life should not be forfeit to satisfy a flawed criminal system. The parents of Alfie Evans should have been allowed to take their child to the Vatican.

I understand the trepidation to have open season for euthanasia. Perhaps we could require patients to undergo counseling before a waiver is provided. Would that soothe your conscious?

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