LAUSR

The Bitter, Expensive Pill at the End of Life To the Editor With initial amazement we read the recent Viewpoint of Shankaran et al.1 The practice of “Big Pharma” to scam patients at one of the most vulnerable moments of their lives with excessive drug cost is far from dignified. Over the years, the practice of euthanasia and/or physician-assisted death has been confronted with fierce opposition. But even the most creative critics using different formats of the “slippery slope” argument would never have come up with the intolerable practices of pharmaceutical firms.2,3 In Belgium (as well has the Netherlands and Luxemburg), euthanasia has been legal since 2002 with strict due care conditions and has been extensively monitored and studied.4 Unique for Belgium is that the law was passed together with the law on patient’s rights and the law on palliative care—the latter with increased funding over time.5 Secobarbital has not been available in Belgium since 1999. Taking inflation into account, the current price in the public pharmacy would have been between $15 and $30 (1500 mg). As an alternative, phenobarbital, in comparable dose, is available for a price between $6 and $24. As part of due care, the general practitioner has to purchase the medication for the patient at a pharmacy. Because of the sensitive nature of the intervention, often the costs are not even charged to the patient (J. Colin, MD, oral communication, April 2017). To put the cost into perspective, euthanasia material as used in hospitals (all technical devices, including intravenous lines, barbiturate, and a muscle relaxant agent) would cost between $90 and $100 at a pharmacy when used in ambulatory patients. Unreasonably high drug cost should not be tolerated in the context of end-of-life interventions.