On Paying People to Die

By Victor Jiang
November 2024

A terminally ill patient is one with an incurable disease that will eventually lead to their demise, typically measured in some short quantity of days, months, or years to differentiate it from the disease of mortality. Treatment is, expectedly, quite expensive and painful—think advanced cancer, ALS, Huntington’s disease, Alzheimer’s, cirrhosis, pancreatitis, late stage AIDS, sickle cell disease, muscular dystrophy, and so on.

Many of these patients have purchased some kind of health insurance. One interesting hypothetical for states governing these interactions is then: 

Is it legitimate for healthcare insurance companies to offer them some kind of large, one-time sum payment in exchange for stopping patient care?

Intuitively, my gut and that of many others leans to yes from the patient’s perspective. It is difficult to argue that providing an additional choice, in pretty much any situation, is a harm. This framework reduces the burden of proof of the side arguing in favour from “we win if we prove this thing is good,” to “we win if we prove this thing is good for even one person who may choose it.”

Then coming up with reasons is easy under a basic utilitarian framework of ethics: people may not want to suffer any longer, and that lump sum payment can simultaneously be easily used to support causes with more long-term utility, e.g. a grandchild’s college tuition, or a two-week trip to the Bahamas before the patient passes.

There is an obvious way to argue against this, and that’s through proving the decision-making process for the patient is coerced. That’s because it is automatically assumed above that people will choose what is best for them; yet external and internal factors may push them to make a disadvantaged choice. In other words, patients who should take treatment might take the lump sum instead, and therefore this choice shouldn’t be provided in the first place to prevent that from happening.

The case for a large degree of coercive factors puts a cloud on previously straightforward analysis.

1. Terminally ill people are often old and mentally unwell (pain, cognitive diseases), thus unsuitable to make life-or-death decisions. Note that a family member or healthcare provider can’t make these decisions either, as that could be akin to murder

2. The patient themselves probably feels obligated to help their family when they should be able to prioritize their own lives

3. Healthcare insurers might have incentives to push them to choose lump sum and their position of authority allows them to significantly control how patients view each option, e.g. the way they describe the painful effects of continuing chemotherapy, not offering the latest medical technologies. More on incentives later

Unfortunately, the ultimate harm of allowing a patient suffering intense pain to live several months longer rather than having taken the lump sum is still very unclear. And while there lingers a question of how much the lump sum payment would be, even a choice of a lump sum payment of $0, aka assisted euthanasia, seems worth providing to someone in genuine agony.

Moreover, there are other potential societal benefits of this choice as well. Given the lump sum payment would have be somewhat less than the cost of terminal illness treatment for healthcare insurance providers to be incentivized to provide them, if some patients choose the payment, costs of healthcare institutions should decrease. For state-run services, they are able to reduce load and spend more in other areas. For private services, a somewhat ideal interpretation is that even if lowered expenses merely end up as surplus profits, this likely boosts investment, probably increases the number of competitors in the market until economic profit is zero, and thus causes companies to offer things like lower premiums and better facilities to attract customers.

Yet despite all this, there is a very interesting case about future patients suffering that come’s about from this choice. It’s one of my favourite ideas in debate, and broadly it goes like this:

Burden of Proof 1: Profit-incentivized pharma companies (a new actor!) trying to make drugs and cures for terminal illnesses need a freak ton of money. Why is this true?

1. These diseases are the most complex diseases out there, often taking decades of time, along with the cutting-edge equipment, top scientists and doctors, etc.

2. Testing is super difficult, requiring lengthy negotiations with governments and hospitals, finding willing patients with the disease, waiting months/years per trial till patients die to see if there’s any benefit of their cure, etc.

3. Companies must make sure 100% there are zero side effects because one catastrophic media case and public relations will cook them. The bar for knowing a cure is 98% good vs 100% good is a massive jump

It’s also worth noting that the vast majority of this kind of research is private pharma rather than, say, the government, because of private-sector efficiency, the research’s significance in a first-mover industry, and the ability of these companies to enjoy massive long-term rewards from successful development (governments switch our every few years).

Burden of Proof 2: A significant number of patients will opt for the lump sum payment. Why is this true?

1. All the previous ideas about the massive benefits of opting for lump sum, which ALSO applies to a significant amount of the population—many poor and middle-class patients might choose the 50k lump sum for their family over a few more months of their own life

2. As described earlier, there are likely intense coercive pressures. And the reason healthcare insurers could be potentially coercive as well is precisely because of earlier incentive analysis: a patient choosing lump sum needs lower costs along with freeing up resources to help more patients and make more profit. Maybe this is choosing not to adopt the latest cutting edge technology for chronic illnesses, or merely the way the doctor describes the options a patient has to choose from.

This means that an already atrociously expensive endeavour could be losing the vast majority of its market. For a profit-driven private pharmaceutical, investing billions of dollars and 30 years into a drug for patients who would rather choose the lump sum instead is simply not a reasonable business strategy. The health insurance company would rather keep pushing its lump sum payment to people rather than buy the drugs and medicine.

So they opt to make more aspirin variants or something, which is a much more assured bang for their buck. The drugs and medicine to cure terminal illnesses are never developed. And even if long term they could become cheap and high quality enough to be widely accessible, they never hit the market. This clears every single contention if left standing because there are billions of both born and unborn people who will experience these same diseases in the future. And given the strongest cases for proposition relate to utilitarian outcomes, this case smashes that ball back to the other side of the court. It might be better to offer someone a choice between death and torture today, but if we are able to eliminate both so that our kids won’t have to make that choice, that is clearly the desirable objective.

But let’s not end the analysis here and consider the potential responses to the above argument. These likely include:

1. Many people, especially those on the wealthier end of the spectrum, are still likely opt to take treatment for the chance to prolong their lives rather than the lump sum, given money doesn’t mean much to them -> these people are most able in society to invest or influence in these types of research as well.

2. Governments likely subsidize research and development to make up for the lack of private incentives given population needs.

3. Due to competition, the profit margins of healthcare companies coercing patients to take lump sum will be reduced to near zero in the long term regardless, aka costing the same amount as the drug -> therefore the profit incentives of healthcare providers to coerce patients to choose the lump sum disappears eventually

But the reverse mitigation to these responses comes out as:

1. The rich of the rich are the 1% of the 1% given the truly wealthy are few in society AND are the ones the least likely to become sick in the first place

2. Governments hate spending on research and development because they never get to see the long-term benefits that another office probably takes credit for 20 years later

3. The healthcare industry tends to be quite oligopolistic in nature, with high barriers to entry and very segregated services to customers (e.g. people don’t change health insurance companies every day). Moreover, these patients are terminally ill, so given their limited time, they are unlikely to have the bargaining leverage in time to ensure exact market prices for lump sum payments. This also relies on the assumption the medicine/drugs have been developed in the first place, which is downstream of this argument that proves they never are

In the end, I think the case against offering the lump sum payment is stronger, at least in ‘debateland.’ The future patients argument is a very clever argument and workaround to the burden proposition set out in this dilemma when proven correctly and in all its parts. 

Inspired by HWS 2016 Round Robin Finals.