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Freakonomics and end-of-life health care

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Stephen Dubner admits that he and the team behind Freakonomics Radio sometimes explore ideas most sane people would leave untouched. This time, Dubner decided to look at the economics of end-of-life health care.

It’s certainly a touchy subject, but also one that most families will have to face at some time in their lives.

Dubner poses the question: “What if someone was suffering from a terminal illness and they had the option of forgoing standard-end-of-life medical care, and instead they could get a cash medical rebate from their insurance companies?”

He’s calling the idea the Glorious Sunset Proposal, and the Freakonomics folks even made a fake commercial so you can hear how it might be pitched.

Dubner took the Glorious Sunsets Proposal and shopped it around to health care experts to see what they thought.

Health care economist Uwe Reinhardt wasn’t having it. Reinhardt says if he were an insurance company CEO, he wouldn’t offer a Glorious Sunsets option. As a health insurer, “your incentive is actually, in many ways, to increase health spending,” Reinhardt said.

When Dubner took the idea to doctor and bioethicist Zeke Emanuel, he wasn’t interested either.

“It’s so cold blooded, it’s so calculating, it’s so utilitarian that it’s not American,” Emanuel told Dubner.

Thomas Smith is an oncologist at Johns Hopkins. Dubner says Smith actually tried a Glorious Sunsets-like experiment years ago that gave cancer patients the option to forgo treatment and keep the money. But the experiment failed.

“Our patients were actually interested, but their doctor/providers weren’t,” Smith said. “It’s pretty hard to look at those two choices and decide what to do.”

It’s clear these three health care experts weren’t thrilled about the Glorious Sunsets Proposal. But Dubner says all three people — and more — that they spoke with did agree on one thing: “If anything in our health care system really needs to be revolutionized right now, it’s end-of-life treatment.”

But Dubner says, in the end, the economics are perhaps the least important factor. He points to what Zeke Emanuel had to say on the matter. “The health care system, instead of talking to a patient and getting it right, we sort of pound on their chest and try to resuscitate them, even when that may not be what they want,” Emanuel said. “And I think trying to get what patients want ought to be our primary focus.” 

Dubner says doctors may soon pay more attention to what patients want. “The Centers for Medicare & Medicaid Services has just proposed a regulation that would actually finally pay doctors to do nothing more than have a conversation with patients about their impending death,” Dubner says.

Maybe it’s not Glorious Sunsets, but it’s “certainly a step in the right direction,” Dubner says. 

Click on the audio player above to hear the fake ad and the full interview.

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