The Ethics and Economics of California’s End of Life Option Act

The End of Life Option Act (EOLOA) in California represents a significant legal and ethical framework for addressing end-of-life care decisions, particularly regarding medical-ethical-legal decisions such as euthanasia. This legislation, signed by Gov Jerry Brown on October 5, 2015, allows terminally ill adult patients the option to request and receive medication to end their lives peacefully.¹

Patients must be at least 18 years old, mentally capable, a resident of California, able to self-administer the medication, and diagnosed with a terminal illness expected to cause death within 6 months. Patients must make 2 oral requests at least 48 hours apart, submit a written request using a designated form, and sign it before 2 qualified adult witnesses. Witnesses must not be related to the patient, potential inheritors, or affiliated with the patient’s health care facility.¹ Physicians must confirm the diagnosis and prognosis, ensure patient capability of decision-making, assess for coercion, inform patients of alternatives, and offer the chance to withdraw the request. Administration of the medication by anyone other than the patient is illegal, and only the patient can make the request.¹

The EOLOA’s provisions are in line with the growing global discourse surrounding patient autonomy and the right to self-determination in end-of-life care. Alongside ethical considerations, the EOLOA also intersects with economic factors. Studies examining the prevalence and content of ethics policies on euthanasia suggest that legalization efforts like the EOLOA can influence the development and prevalence of written institutional policies on end-of-life decisions.² The economic implications of such legislation include considerations of health care costs, resource allocation, and the impact on health care delivery systems.

Moreover, the EOLOA is sure to have implications for health insurance coverage and reimbursement policies. Insurers may need to revise their policies to accommodate the costs associated with providing medical aid in dying (MAID), including physician consultations, medication, and supportive services. The extent of insurance coverage for MAID-related expenses would vary depending on factors such as the patient’s insurance plan, the specifics of the MAID procedure, and state regulations governing health care coverage.

Following the EOLOA, there could be a shift in focus away from traditional palliative care services toward MAID as a preferred end-of-life option. This shift might result in reduced availability of resources and support for patients who choose to pursue other avenues of end-of-life care, such as hospice or palliative care. Additionally, health professionals may face ethical dilemmas or moral distress if they perceive pressure to prioritize MAID over other forms of end-of-life care.

There is also a concern that the availability of MAID under the EOLOA may create opportunities for coercion or abuse, particularly among vulnerable populations such as older individuals, individuals with disabilities, or economically disadvantaged individuals. Patients could feel pressured to choose MAID due to financial, emotional, or social factors, and caregivers or family members may unduly influence end-of-life decisions. This erosion of trust could have long-term consequences for patient-provider relationships and health care outcomes.³

By empowering patients to make decisions about their own care, the act could also lead to more efficient resource allocation within the health care system, as patients choose interventions based on their preferences and values.⁴ However, opponents raise concerns about the potential for abuse, coercion, and the erosion of trust in the patient-physician relationship.

References

1. California End of Life Option Act (EOLOA). UCLA Health. Accessed June 10, 2024. https://www.uclahealth.org/patient-resources/support-information/patient-education/california-end-life-option-act-eoloa

2. May P, Normand C, Cassel JB, et al. Economics of palliative care for hospitalized adults with serious illness: a meta-analysis. JAMA Intern Med. 2018;178(6):820-829. doi:10.1001/jamainternmed.2018.0750

3. Wilson KG, Scott JF, Graham ID, et al. Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide. Arch Intern Med. 2000;160(16):2454-2460. doi:10.1001/archinte.160.16.2454

4. Thomson JJ. Physician-assisted suicide: two moral arguments. Ethics. 1999;109(3):497-518. doi:10.1086/233919