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Editor's Correspondence
December 7/21, 1998

Physician-Assisted Suicide

Arch Intern Med. 1998;158(22):2513. doi:

In reply

Malter suggests that despite our careful and even-handed treatment of the link we discovered between cost containment and physician-assisted suicide (PAS), any note of caution regarding the legalization of PAS in light of this finding is likely to be the result of uncritical thinking caused by personal moral bias. However, we would argue that the fact that Malter is unwilling to entertain any caution in interpreting these startling results suggests that it is his thinking that might be clouded by personal moral bias. As Malter acknowledges, we explicitly point out in our article that a retrospective study does not establish a causal relationship. However, it is equally true that a causal explanation cannot be excluded. That physicians might be motivated, at least in part, to engage in PAS to conserve health care resources is perfectly compatible with our data. As we also point out in our article, other explanations, such as a view of rationality that simply renders both cost containment and PAS the "rational" things to do, are also plausible. This is the interpretation that Malter prefers. However, it then seems rather supercilious of Malter to suggest that his is the "true" rationality and that all opposition to PAS is simply irrational. Not all persons share Malter's view of rationality.1 Finally, we agree that the association we found between cost-conscious practice and support for PAS, whatever its cause, suggests that it was no accident that Oregon was the first state in the Union to embrace both explicit health care rationing and PAS. However, a very large minority of Oregonians opposed the legalization of PAS. The very suggestion that opposition to either cost containment or PAS is simply irrational suggests a way in which undue pressures might be brought to bear on patients who are hesitant about PAS.2 "Naturally," the enlightened might say, "you agree that it is irrational to waste scarce health care resources. Why then can't you also see how it is irrational for you to continue suffering and simultaneously wasting scarce health care resources when PAS is an option?" Our study does not address whether such questions might be asked. However, to argue that our study does not raise such issues seems to imply a moral blind spot. We have explicitly entertained many possible interpretations of the data, including that offered by Malter. We conclude only that the data suggest caution and further study before embracing PAS. That seems a prudent and fair-minded approach.

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