Pretty soon, people will be able to start shopping for health insurance on the infamous Obamacare exchanges. In North Carolina, one of the states asking the feds to take the lead in this effort, only one insurer is offering insurance coverage in every county of the state. That is Blue Cross Blue Shield, and they just announced their rates. Here they are:
What do you think: look like any good deals out there?
The Centers for Disease Control and Prevention defines suicide as: “Death caused by self-directed injurious behavior with any intent to die as a result of the behavior .” The Merriam-Webster dictionary defines it as: “the act or an instance of taking one’s own life voluntarily and intentionally especially by a person of years of discretion and of sound mind.” By both of those definitions, the act of a terminally ill person ingesting an overdose of pills with the intention of ending their life would qualify as suicide.
To that extent, Kathryn Tucker, in her response to my earlier post, was wrong to characterize my use of the term “physician assisted suicide” as being “inaccurate.”
Instead of the word “assisted,” she prefers the word “aid.” But logically and technically, I cannot see a difference between “physician assisted suicide” and “physician aid in dying.” Nor do I see a moral difference. As I pointed out in my post, I have been a long time supporter of people’s rights to end their lives when they are suffering from terminal illnesses, and of the appropriateness of physicians helping them do this.
But Tucker made some outstanding points in her essay, ones I am very grateful to have learned from, and ones that are very much in the spirit of my original post. She points out that the way people perceive words matters, separate from the specific definition of those words. She points out that the word “suicide” is stigmatized. Many, perhaps most, acts of suicide are the acts of people who are not in their right state of mind. Most of us physicians are trained, correctly, to see suicide as a warning that a patient needs help, and to treat suicide as something to prevent rather than assist in.
I cannot dispute when a terminally ill person says that describing them as suicidal is “disrespectful and hurtful.” But I can tell you this. I did not use the word suicide with any intention to be disrespectful or hurtful. The goal of my essay was to point out that it’s a mistake to equate a person ending their own life with the concept of dignity. It can also be dignified not to end one’s life. It can be dignified to fight all the way to the end, with the most aggressive possible care. It can be dignified to enroll in hospice care, and die naturally without taking any substances that hasten one’s end. And yes, it can be dignified for a terminally ill person to take control over their own destiny, and ingest medications that end their life.
Thanks to Kathryn Tucker, I will not use the phrase physician-assisted suicide again, except to make sure people understand that the phrase carries connotations that are unnecessarily pejorative.
The below post is a response to my article Death With Dignity Should Not Be Equated With Physician Assisted Suicide by Kathryn L. Tucker, JD. My own thoughts on her response are here.
In a Forbes.com oped, “Death With Dignity Should Not Be Equated With Physician Assisted Suicide, Duke University physician Peter Ubel writes: “I think it is wrong-headed to equate assisted suicide with the concept of a dignified death.”
Dr. Ubel’s use of the inaccurate, value-laden term “assisted suicide” to describe a terminally ill patient’s choice to shorten a dying process that the patient finds unbearable – as some journalists also wrongly do – is concerning. Words matter.
Medical, health policy and mental health professionals recognize that the term “assisted suicide” is inaccurate, biased and pejorative in this context. Increasingly, these organizations have adopted the more accurate and neutral term “aid in dying” to refer to this choice.
The nation’s largest public health association, theAmerican Public Health Association, adopted a policy supporting aid in dying, recognizing that: “the term ‘suicide’ or ‘assisted suicide’ is inappropriate when discussing the choice of a mentally competent terminally ill patient to seek medications that he or she could consume to bring about a peaceful and dignified death.” The policy emphasizes: “the importance to public health of using accurate language.” The American Medical Women’s Association has adopted similar policy, as have a number of other national medical organizations.
A growing number of states, including Oregon, Washington, Montana,Vermont and Hawaii, permit mentally competent, terminally ill patients to obtain medications they can ingest to bring about a peaceful death if their suffering becomes unbearable. The Oregon, Washington, and Vermont lawsclearly state: “Actions taken in accordance with [the Act] shall not, for any purpose, constitute suicide, assisted suicide, mercy killing or homicide, under the law.”
Terminally ill patients do not want to die but are facing an imminent death, most after long efforts to cure their illness and heroic efforts to palliate symptoms. Despite excellent pain and symptom management, some find the dying process unbearable and want to achieve a peaceful death. Patients who can choose aid in dying do not consider that they are committing “suicide,” and find the suggestion that they are deeply offensive, stigmatizing and inaccurate. Many have publicly expressed that the term is hurtful and derogatory to them and their loved ones.
“All I am asking for is to have some choice over how I die,” wrote terminally ill patient Louise Schaefer in a letter to The Sacramento Bee. “Portraying me as suicidal is disrespectful and hurtful to me and my loved ones. It adds insult to injury by dismissing all that I have already endured; the failed attempts for a cure, the progressive decline of my physical state and the anguish which has involved exhaustive reflection and contemplation leading me to this very personal and intimate decision about my own life and how I would like it to end.”
Dying patients who choose aid in dying want to live, as evidenced by the fact that more than one-third of these terminally ill patients don’t ingest the medication even after they obtain it. But they derive great comfort knowing they have that option. For those who do take the medication to achieve a peaceful death, they have been able to cross the threshold to death in a manner consistent with their values and beliefs, and consider this choice to have enabled them to exercise a final act of autonomy consistent with how they have lived their whole life.
As noted philosopher and law professor Ronald Dworkin observed in his book Life’s Dominion (Knopf 1993): “…we live our whole lives in the shadow of death…we die in the shadow of our whole lives….We worry about the effect of life’s last stage on the character of life as a whole, as we might worry about the effect of a play’s last scene or a poem’s last stanza on the entire creative work.” We ought not insult and diminish this choice by applying an inaccurate, pejorative term. Words matter.
Kathryn L. Tucker, JD, is the Director of Advocacy & Legal Affairs for the nation’s leading end-of-life advocacy, education and support organization, and teaches Law, Medicine and Ethics at Loyola Law School in Los Angeles.Compassion & Choices
Recently I had the pleasure of reading Rich Cohen’s wonderful book: The Fish That Ate the Whale – the Life and Times of America’s Banana King. The book tells the story of Samuel Zemurray, a true rags to riches story, a man who started by spending his entire life savings – all $150 – to buy bananas that would’ve otherwise been thrown out, and selling them stop to stop out of a train car. He eventually ended up running United Fruit, the company most of us know for selling Chiquita Bananas. Cohen’s book is wonderful in large part because Sam the Banana Man was an absolutely fascinating person, admirable for his work ethic and entrepreneurial creativity, and horrifying the lengths he would go to – including overthrowing Central American governments standing in his way – to promote his business interests.
The book is also wonderful because of Cohen’s colorful writing. Let me share just a few examples with you. It starts right with the opening sentence of the book, which captures Cohen’s style well: “Sam Zemurray spoke with no accent, except when he swore, which was all the time.”
Cohen’s descriptions of the Central American landscape are equally colorful: “If you’re going to build in the jungle, build fast. Anything left for a season is lost. It turns first into a ruin, then into a story, then is forgotten altogether.”
To his descriptions of banana farming: “In the jungle, after a heavy rain, you can hear the banana trees growing.” And that’s not just an overwrought description. Cohen points out that banana plants can grow 20 inches a day.
And here’s something you might not have known about bananas: “The scientific name for the plant, Musa paradisaica, the fruit of Paradise, carries evidence of a medieval legend – that it was the banana, not the Apple, that the snake used to tempt Eve in the Garden of Eden, a belief that, considering the shape of the fruit and the nature of man’s Fall, makes sense.”
There is Cohen’s take on late night thoughts: “After all, some of the most profound moments of any life are lived between three and four in the morning, when you stare at the ceiling as the silence roars.”
I wonder what time of day Cohen came up with that sentence!
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A recent news article reported that a grocery store in Durham, North Carolina now offers healthy checkout aisles for people interested in minimizing temptation. Ring up your groceries in that aisle, and you won’t be surrounded by candy bars and bags of chips.
On the other hand, I’m guessing you will still be surrounded by magazine covers filled with Miley Cyrus twerking, whatever that is.
Most people would say they would prefer to work in a job with interesting and fulfilling opportunities. But new research shows that people may pick a boring job over a stimulating one if they perceive they aren’t being paid enough for extra effort.
Duke University Fuqua School of Business marketing professorPeter Ubel and David Comerford, an assistant professor at Stirling University, explored the idea of “effort aversion,” or why people choose to put forth less effort even if it means less personal satisfaction. The results of their studies, “Effort Aversion: Job Choice and Compensation Decisions Overweigh Effort,” were published last month in the Journal of Economic Behavior and Organization.
“We found even when an effortful job would be more interesting and enjoyable than one requiring less effort, people might price themselves out of the job market because they feel their effort needs to be rewarded,” Ubel said.
The researchers conducted several studies that showed how wages impact a job seeker’s willingness to take on more challenges. In the first experiment, 144 people answered a questionnaire offering the choice of two short-term jobs at a cultural festival. Participants could either choose to be an usher (which would require publicizing the event, cleaning up after and escorting performers) or a monitor (which would only require alerting a security guard if needed.) Results showed that while most people (82 percent) preferred the job of usher, 36 percent would only take the job if it paid more than the monitor.
“Ask someone which of two jobs they like better, and they will often pick the more interesting job, even if it requires more mental or physical effort,” Comerford said. “But ask them how much the two jobs should pay, and now that their mind is focused on wages, they often conclude that all that extra effort ought to be rewarded, otherwise they will take the boring job.”
In the second study, 74 graduate students agreed to take part in a short film. They could choose the role of worker (which would require doing a word puzzle for almost five minutes) or on-looker (sit and watch others.) Again, results showed most people found the role of worker more enjoyable (66 percent), but of that group only 18 percent agreed to solve the word puzzles without regard to whether they would receive more money than the onlookers.
“What these two studies showed us is if you put the issue of wages in front of people, all of a sudden that becomes a primary concern. They are focusing on what they perceive as fair compensation, rather than nonmonetary aspects of the job, such as social value or even whether the job is interesting,” Ubel said.
In a third study, researchers wanted to understand if “effort aversion” could be easily overcome. Eighty people surveyed at airports were asked about a hypothetical film-shooting scenario similar to the previous study. Some were asked to rate the roles of workers versus on-looker based on enjoyment before considering wages. A second group was asked to set wages for the jobs before thinking about the enjoyment.
The people who considered enjoyment first were more likely to pick the job they said they would enjoy most. However, the results were not statistically significant enough to conclude that “effort aversion” could be overcome by simply thinking about enjoyment before wages.
“I can see lots of good reasons why your gut would tell you not to work unless you get paid more than you’d get for doing nothing,” Comerford said, “but the lesson I take from these studies is that that reaction risks leaving you bored and unhappy.”
The hospital price transparency bill that was signed into effect on August 21 has elicited criticism from the Duke health community.
House Bill 834 mandates that hospitals and medical care agencies in North Carolina—including Duke University Medical Center—provide pricing information on 140 of the most common health care procedures to the Department of Health and Human Services. The DHHS will require information from hospitals on the exact pricing of the 100 most common in-patient treatments, 20 surgical procedures and 20 imaging services. The information will be made available to the public online.
The bill is intended to protect patients’ rights and help them make informed financial decisions regarding health care treatments, according to a press release from Gov. Pat McCrory’s office. Before the law passed, for example, hospitals could file a lien on a patient’s residence in order to collect unpaid medical bills in some situations, but now the practice is banned… (Read more here)
Imagine you are the breadwinner for a family of four, and have been out of work for a while in the recessionary economy. Your financial situation is so dire that you have had to enroll your family in Medicaid. Then you find a job, not one that will make you wealthy but one that pays a decent subsistence wage. That’s great news for your family except for one fact—you will no longer qualify for Medicaid. And your new employer does not provide health insurance. Fortunately, you will qualify for a federal subsidy through the new health insurance exchanges that are part of Obamacare.
Have you been saved by the federal safety net?
Yes and no, because you will first be stuck in what health policy experts call aninsurance churn, caught in “the Medicaid-exchange divide.” In the time between losing Medicaid and receiving insurance through the exchange, your family could be one serious illness away from financial calamity.
It is this churn that has some policy experts contending that Arkansas’s plan—to use its federal Medicaid dollars to purchase insurance for its low-income population on the exchanges—might be the key to helping people maintain more consistent healthcare coverage as their economic circumstances wax and wane… (Read more and view comments at Forbes)
I just came across this picture, from the Kaiser family foundation website, illustrating just how often employee healthcare costs take up 10% or more of employee payroll. The number was already pretty high more than a decade ago, but it’s gotten even higher:
For large employees, this amounts to almost $5 per hour put aside for healthcare costs:
It will be interesting to see what happens to these numbers the next few years, as the Affordable Care Act gets fully implemented. I, for one, don’t expect to see dramatic changes. But I hope I am wrong.
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The urologist broke the news: “Out of 12 cores, three were positive for cancer, so you have a small amount of cancer.”
He would soon explain the treatment choices—surgery, radiation, or active surveillance (watching the cancer closely with blood tests and biopsies). He described each option in elaborate detail, because he knew that the “right choice” would depend on what his 70-year-old patient thought about the pros and cons of treatment versus surveillance.
But before explaining the choices, the urologist wanted to make sure that the man in front of him understood the limited extent of his cancer:
We grade prostate cancer on how it looks under the microscope. We give it a score between 6 and 10.
Is that the Teason? the patient asked.
That’s the Gleason score.
Oh, Gleason score, OK.
Yep, so 6 is what we consider the lowest grade, least aggressive-looking, but it’s just abnormal enough for us to call it cancer. If it were any less than that—if there were less atypical-looking cells—we couldn’t call it cancer. So it’s just enough to get a grade of cancer, and then that goes all the way up to a score of 10, which is very abnormal looking and is more aggressive.
But 6 is the beginning number?
Yes, 6 is the least aggressive, 10 is the most aggressive, the doctor clarified.
I’m used to like, 1, the patient said, laughing.
Yeah well, the way we typically split it up is into thirds; low risk, intermediate risk, and high risk.
Right, said the patient.
Low risk is Gleason 6, intermediate is usually 7’s—3+4 or 4+3, depending on how it looks under the microscope. And then 8, 9, and 10 are all high risk. Yours is an intermediate risk. So it’s in the middle. It is 3+3 and 3+4, so just enough of the atypical cells of the grade 4 to make it 3+4, which means you’re intermediate risk.
The conversation is remarkable not just for its inscrutability but for the very fact that it took place… (Read more here)