Here are the economics of dying

Just over 30 years ago, Colorado Gov. Dick Lamm drew national notoriety by stating the terminally ill have a “duty to die and get out of the way.” As a young economist I applauded his frankness as he removed emotion from the analysis. The governor went on to explain that with technological advances, we were keeping people alive who were suffering dearly. He felt such policy could destroy the nation’s economy. As I look at the senior tsunami heading our way, I fear he was on target, even though it may not be technology per se that will consume our resources.  

Dying is culturally defined. It was quite common among nomadic tribes for the elderly to disappear into the bush when they could not keep up. In Western culture, perhaps due to our roots in Judeo-Christian ethics, many of us “fight for life” until the end. 

Since Gov. Lamm’s assertion, subsequent research found the amount spent in the last year of life has remained pretty steady at about 27 percent of Medicare expenditures. So by this metric, expenses at the end-of-life are increasing only in proportion to our 65-plus population and health care inflation. However, assuming Medicare represents about 75 percent of total end-of-life expenditures, the U.S. spends about 1.4 percent of gross domestic product on the terminally ill’s last year of life, or about $215 billion in 2014. This doesn’t sound too bad, but consider that we spend 3.7 percent of GPD on all primary and secondary education in the nation. This is where I pause. The rational allocation in any economic system is to invest in opportunity for the future – not legacies of the past. As the governor said, “Let the other society, our kids, build a reasonable life.”

Perhaps my perspective on this issue was reinforced by my mother’s death. Scar tissue in her lungs made each breath increasingly difficult. When she learned she might survive a year or two confined to bed, she made the courageous choice to remove her own oxygen mask, suffocating in minutes. My father-in-law died of cancer at 89. The health care system saw little reason to treat the cancer and neither did he. Knowing my mother had controlled her own destiny, he asked me how he might do the same. I inquired with the hospice professionals and they were clear about the lines they could not cross – they would provide comfort and could withhold life support, but they could not assist him ending his life.

From an economic perspective, the equation is quite simple. Dying is expensive under the current paradigm. From the human perspective, some people may want to fight to the end, and that is their right. I only ask who pays. On the flip side, shouldn’t people also have the choice to die with dignity?  The Swiss, with their efficient focus, have allowed medically assisted suicide since 1941. In the U.S., five states have laws supporting death with dignity. In my opinion, Colorado should join in.

A good friend of mine is struggling to survive. He is dying of long-term complications of diabetes and is in excruciating pain. It took a while, but health professionals finally realized the best thing was to be upfront and deny surgery. Instead, doctors want to prescribe comfort drugs, but Medicaid is slow to approve the medicine. He should have dignified options at this point.

At the end of the day, public policy should focus on three items: Medicare and Medicaid should accommodate reasonable costs with some degree-based cost sharing. If an individual or family wants medical efforts to fight for life, then that individual or private insurance should bear the full cost. Finally, people who are terminally ill or have a very poor quality of life should have the option of death with dignity.