The cost of dying
Some say assisted suicide is about choice. Others say it could end up being about money.
Doctors found it in June, and by the end of summer, the 64-year-old Everett preschool owner was back on her feet, ready to begin her retirement years.
In November, the tumor was back again. It worked like a thief, quietly and quickly, and within months it had robbed Beth Chowen of her ability to move, to live in her own home, even to speak.
At first, Medicare paid for everything, her husband, Terrence Chowen, said. Doctors said there was nothing more they could do. Medicare pulled out, he said.
"Medicare would only cover it if you were recuperating or while there's hope that you might recuperate," Chowen said.
The family barely qualified for Medicaid, which covered Beth Chowen's time in a nursing home, Chowen said. If it hadn't, Chowen said he probably would have had to sell their home.
"Of course a lot of folks are worse off than I am and they would have to decide," Chowen said. "Spend the money or let the person die."
The debate over Initiative 1000, a movement to legalize physician-assisted suicide in Washington state, is largely focused on the ethics of whether a terminally ill person should be given the choice to take a lethal dose of medicine.
But when it comes to the practice of physician-assisted suicide, these are the facts:
About 30 percent of all Medicare dollars are spent during the last months of a person's life, according to the American Medical Association.
In Oregon, the only state that has legalized physician-assisted suicide, a lethal dose can cost less than $100.
If voters approve Initiative 1000 in November, opponents say the argument over ethics could easily become an argument over money. And the poorest people could end up paying with their lives.
Backers of physician-assisted suicide say it's not about money, but choice, and whether the terminally ill should be allowed skip past months of suffering and hasten an already imminent death.
The initiative, also known as the Death with Dignity Act, was authored by former Gov. Booth Gardner. It would only allow people who have been given less than six months to live to request suicide. Each patient would be required to make verbal and written requests for lethal medication, and would be required to observe a waiting period.
The initiative does not require a patient to discuss the decision with family members or meet with a mental health professional.
Voters should assume that the initiative is just the first step in legalizing suicide, said Dr. Patricia O'Halloran of the Coalition Against Assisted Suicide. Gardner, who suffers from Parkinson's disease, has said that he hopes the law would one day expand to offer the same option to people with debilitating or chronic illnesses.
It's also not clear how the initiative might be handled by health insurance companies. With the option of death, there's no guarantee that an insurance plan would pay for a few extra months of life.
"It's one thing for voters to vote on this, but unintended consequences are huge with Initiative 1000," said O'Halloran, who practices in Tacoma.
O'Halloran and other initiative opponents point to the case of Barbara Wagner, an Oregon woman diagnosed with lung cancer. News reports in August focused on how Wagner, 64, asked the state-run Oregon Health Plan, a health insurance provider, to pay for a $4,000-a-month medication. She reportedly got back a letter from Oregon Health Plan denying her request. It listed other options, including a $50 lethal dose, that would be covered under the plan.
Wagner isn't the only Oregon person who has received such a letter, O'Halloran said. She said she's read reports that the Oregon Health Plan had been sending letters listing options including suicide to terminally ill patients for some time.
The suggestion of suicide could pressure people who may already worry that their treatment costs too much or that their families have been shouldering their daily care, O'Halloran said.
"When you legitimize suicide as an option, people will consider it," she said.
Wagner's case shouldn't be used as an attack of physician-assisted suicide, said Anne Martens, spokeswoman for Yes on I-1000.
"The woman in Oregon was denied an experimental and unproven treatment," Martens said. "That was after Medicaid had already paid thousands and thousands of dollars for her chemotherapy."
Wagner was given the option to end her own life and she declined, Martens said.
"If anything, it proves that patient choice is paramount, as Ms. Wagner chose not to use the Death with Dignity Act, and nobody forced her to," Martens said.
The initiative has nothing to do with money, Martens said.
According to a 1998 study by the New England Journal of Medicine, 2.7 percent of all people who die each year would choose physician-assisted suicide were it a legal option. Based on 1995 dollar figures and statistics culled from The Netherlands, where physician-assisted suicide has been decriminalized since 1993, the health-care industry would save $627 million each year were the practice legalized nationwide. That's less than 1 percent of the total amount spent on health care.
"In the end stages of cancer, there are no heroic treatments left," Martens said. "People are mostly in hospice care, and hospice care at the end of life is relatively inexpensive."
Any cost-savings for choosing physician-assisted suicide is "negligible," she said.
Senior citizens, especially those struggling to make ends meet, are increasingly vulnerable when it comes to health care, said Robert Quirk, social services director at Senior Services of Snohomish County. High housing costs pinch those with fixed incomes, and subsidized health care plans often provide hit-or-miss coverage.
Plans that cover general care at Everett Clinic may not cover the specialized care a disabled person needs, Quirk said. Coverage plans are moving targets, changing every year, so it's difficult to know for sure whether one plan or another will work in emergency care or long-term care situations.
"Folks definitely get pushed into managed care plans," Quirk said.
There's no reason anyone should go broke trying to pay for health care, but it's easy to get into a financial bind without the right information, said Peter Russell, a social worker who helps seniors at the Everett Senior Center select insurance plans.
It's a relief to most people when someone can help them navigate the health-care bureaucracy, and especially when they discover that they can sign advance directives to ensure they won't be forced into an artificially prolonged life when their bodies fail, Russell said.
"They'd rather go out with dignity," he said.
That was Chowen's last wish for his wife, Beth. The couple signed advanced directives shortly after the 2005 death of Terri Schiavo, a brain-damaged woman caught between the wishes of her husband and her parents.
The tumors in Beth Chowen's brain grew so fast that she wouldn't have had a chance to ask to end her own life, had it been legal.
Terrence Chowen made the decision for her.
"I had them stop giving her food," he said. "There was just water, to keep her hydrated, and painkillers."
Two weeks later, she was gone.
On the back of the program at her funeral, Terrence Chowen printed a poem: "Miss me, but let me go."
Reporter Krista J. Kapralos: 425-339-3422 or firstname.lastname@example.org.
More on I-1000
For more information on Initiative 1000:
Yes on I-1000: www.itsmydecision.org, 206-633-2008
Coalition Against Assisted Suicide: www.noassistedsuicide.com, 206-337-2091.
For data on physician-assisted suicide in Oregon, go to www.oregon.gov/DHS/ph/pas/index.shtml.
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