About Those “Death Panels”…..
(Originally posted on What’s Wrong with the World)
This, just up, from Sarah Palin on her Facebook page (with footnotes too!):
Yesterday President Obama responded to my statement that Democratic health care proposals would lead to rationed care; that the sick, the elderly, and the disabled would suffer the most under such rationing; and that under such a system these “unproductive” members of society could face the prospect of government bureaucrats determining whether they deserve health care.
The President made light of these concerns. He said:
“Let me just be specific about some things that I’ve been hearing lately that we just need to dispose of here. The rumor that’s been circulating a lot lately is this idea that somehow the House of Representatives voted for death panels that will basically pull the plug on grandma because we’ve decided that we don’t, it’s too expensive to let her live anymore….It turns out that I guess this arose out of a provision in one of the House bills that allowed Medicare to reimburse people for consultations about end-of-life care, setting up living wills, the availability of hospice, etc. So the intention of the members of Congress was to give people more information so that they could handle issues of end-of-life care when they’re ready on their own terms. It wasn’t forcing anybody to do anything.” [1]
The provision that President Obama refers to is Section 1233 of HR 3200, entitled “Advance Care Planning Consultation.” [2] With all due respect, it’s misleading for the President to describe this section as an entirely voluntary provision that simply increases the information offered to Medicare recipients. The issue is the context in which that information is provided and the coercive effect these consultations will have in that context.
Section 1233 authorizes advanced care planning consultations for senior citizens on Medicare every five years, and more often “if there is a significant change in the health condition of the individual … or upon admission to a skilled nursing facility, a long-term care facility… or a hospice program.” [3] During those consultations, practitioners must explain “the continuum of end-of-life services and supports available, including palliative care and hospice,” and the government benefits available to pay for such services. [4]
Now put this in context. These consultations are authorized whenever a Medicare recipient’s health changes significantly or when they enter a nursing home, and they are part of a bill whose stated purpose is “to reduce the growth in health care spending.” [5] Is it any wonder that senior citizens might view such consultations as attempts to convince them to help reduce health care costs by accepting minimal end-of-life care? As Charles Lane notes in the Washington Post, Section 1233 “addresses compassionate goals in disconcerting proximity to fiscal ones…. If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?” [6]
As Lane also points out:
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that’s an incentive to insist.
Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic. [7]
Even columnist Eugene Robinson, a self-described “true believer” who “will almost certainly support” “whatever reform package finally emerges”, agrees that “If the government says it has to control health-care costs and then offers to pay doctors to give advice about hospice care, citizens are not delusional to conclude that the goal is to reduce end-of-life spending.” [8]
So are these usually friendly pundits wrong? Is this all just a “rumor” to be “disposed of”, as President Obama says? Not according to Democratic New York State Senator Ruben Diaz, Chairman of the New York State Senate Aging Committee, who writes:
Section 1233 of House Resolution 3200 puts our senior citizens on a slippery slope and may diminish respect for the inherent dignity of each of their lives…. It is egregious to consider that any senior citizen … should be placed in a situation where he or she would feel pressured to save the government money by dying a little sooner than he or she otherwise would, be required to be counseled about the supposed benefits of killing oneself, or be encouraged to sign any end of life directives that they would not otherwise sign. [9]
Of course, it’s not just this one provision that presents a problem. My original comments concerned statements made by Dr. Ezekiel Emanuel, a health policy advisor to President Obama and the brother of the President’s chief of staff. Dr. Emanuel has written that some medical services should not be guaranteed to those “who are irreversibly prevented from being or becoming participating citizens….An obvious example is not guaranteeing health services to patients with dementia.” [10] Dr. Emanuel has also advocated basing medical decisions on a system which “produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.” [11]
President Obama can try to gloss over the effects of government authorized end-of-life consultations, but the views of one of his top health care advisors are clear enough. It’s all just more evidence that the Democratic legislative proposals will lead to health care rationing, and more evidence that the top-down plans of government bureaucrats will never result in real health care reform.
[1]See http://blogs.abcnews.com/politicalpunch/2009/08/president-obama-addresses-sarah-palin-death-panels-wild-representations.html.
[2]See http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf
[3]See HR 3200 sec. 1233 (hhh)(1); Sec. 1233 (hhh)(3)(B)(1), above.
[4]See HR 3200 sec. 1233 (hhh)(1)(E), above.
[5]See http://edlabor.house.gov/documents/111/pdf/publications/AAHCA-BillText-071409.pdf
[6]See http://www.washingtonpost.com/wp-dyn/content/article/2009/08/07/AR2009080703043.html].
[7]Id.
[8]See http://www.washingtonpost.com/wp-dyn/content/article/2009/08/10/AR2009081002455.html].
[9]See http://www.nysenate.gov/press-release/letter-congressman-henry-waxman-re-section-1233-hr-3200.
[10] See http://www.ncpa.org/pdfs/Where_Civic_Republicanism_and_Deliberative_Democracy_Meet.pdf
[11]See http://www.scribd.com/doc/18280675/Principles-for-Allocation-of-Scarce-Medical-Interventions.
FB:
Only the naive with child-like faith in government believe otherwise. Mrs. Palin has done her homework.
Let’s flip this question around, and ask, if you don’t like the provisions in the current House bill (actually one of three, but who’s counting), what SHOULD Medicare do about end-of-life care consultations? What would anybody here do differently from this bill?
Should doctors be forbidden to discuss options with patients? Should the patient be required to raise the issue themselves? Should doctors be instructed to press for one kind of decision over another? Should patient be discouraged from making out living wills or health care powers of attorney? Should all patients be forced to receive maximal life-extending care, no matter how expensive (or painful)? Who should make decisions about these issues?
Give me an alternative. And if doesn’t include getting medical input from a doctor, explain why that’s a good idea. If it does, explain how it’ll work differently from the provision already being discussed.
Muskrat:
It’s the whole very creepy, Orwellian fact of the government codifying this into law. That doesn’t bother you?
They are seeking to usurp the role of the family, personal Dr., and community in a very private matter. It is one of the most repugnant things I could ever imagine.
Davy:
Just like they did with Terry Schiavo when they trampled Michael Schiavo’s rights and Florida state’s rights?
This bill actually ensures the right to individuals, not the insurance company bureaucrat nor government:
http://www.washingtonmonthly.com/archives/individual/2009_08/019436.php
BC:
Uh, I believe it was Terry’s life that was at stake, not her husband’s. No one has the “right” to starve another human being to death. You defend that?
Yeah, this administration and Congress is all about ensuring individual rights. Their record clearly indicates that, doesn’t it?
Michael Schiavo had a “right” to allow his wife to starve to death (a cruel & painful death, BTW) when it was clear per physician documentation that she was responsive, that PVS was never a diagnosed condition for Terry, despite what Michael said? What about Terry’s right to life & the rights of her parents who were willing to care for her the rest of her natural life? Sorry, bc, that doesn’t fly with me.
Frankly put, physicians do not have the time to discuss this “end of life” information with patients now. So where will this time come from should Obamacare be passed into law?
I work for a major West Coast medical center & our internal medicine docs, who see mostly 65+ patients, do not have this sort of time. If they took that time they’ll be forced to see fewer patients each day & these patients take more time to care for as it is because they tend to have more medical conditions in need of active monitoring. Considering that Baby Boomers are rapidly heading into senior citizen status, there simply will not be enough physicians to provide such “chats” on that large a scale.
And, really, we’re not talking about a simple, *here are your options* sort of meeting here, are we? It’s simply not an easy decision for most folk to make & it’s a very frightening one, too. Obama is being very cavalier in his response to Palin’s point. (And her point is a slam-dunk, BTW.) But then, Obama & the Dems are being cavalier about everything since he took the oath.
God help us all!
It is absolutely absurd to suggest that our current Executive and Legislative branches are desirous of providing our citizenry with greater/increased individual rights and/or freedoms. Such a notion would be laughable if this march towards total socialism were not happening so quickly and were we not, day by day, becoming an even bigger nanny-state than we already are. It is not our government’s role, or perhaps “responsibility/duty” is more apt, to address such issues at all or to be so thoroughly mired within them.
“What should Medicare do about…” it? Surely you can’t be serious.
Kudos to Ms. Palin. As others have stated, she has definitely done her homework and her analysis remains firmly on-point.
“Just like they did with Terry Schiavo when they trampled Michael Schiavo’s rights and Florida state’s rights?”
Michael was living with another woman in a marital state (though legally not married to her) in which he sired two children (though legally “bastards”) while he had the power of attorney over another woman to which he was legally married.
My God, the guy had too many rights; not too few!
So, to summarize, the consensus here is that:
a) It’s very important to have a clear and accurate living will so that you don’t wind up with your wishes guessed at, litigated over and possibly disrespected as (some assert) Mrs. Schiavo’s were; and
b) It’s very important that you not seek the advice of a medical professional in drawing up your living will, because the doctor helping you will just do whatever the payer wants. Because whether it’s the government or an insurance company, the payer will almost never be the patient.
So in even shorter form, people are saying “it’s important that the most critical document you ever draw up be done in ignorance of anything resembling a fact.”
“…seek the advice of a medical professional in drawing up your living will…”
Pardon?
To answer: should you be an individual who would consult a plumber as to the in’s and out’s of riparian rights, then go right ahead – consult a “medical professional” as to your advance directive. To all others, leave the “medical professionals” out of it and simply consult with an attorney knowledgeable in such affairs.
Sorry — I was using “living will” as a shorthand for “advance medical directive” or whatever you call the document that details your directives for what kinds of treatment you want given in various situations. I realize “living will” can encompass more situations than medical cases, and as such should be drawn up by a lawyer. But whatever you call the document, the parts of it that deal with medical decision-making would be helped by the advice of a doctor, yes? If you’re making decisions about plumbing, you talk to a plumber. Make decisions about tree removal, call an arborist. Decisions about medical care — doctor, right?
Muskrat –
Truly it appears you have digressed far from the scope of the original post. This is not about how to most proficiently compose an advanced directive. Rather, it’s about the role of government (or, to be precise, the lack of role it should have) with respect to such an issue; particularly with respect to the government making such decisions – either directly or indirectly.
Taking a bit of digression myself, I merely commented on your vast over-simplification of “the consensus” and your rather amusing suggestion that it would be somehow inexcusable to exclude a “medical professional” from the composition of an advance directive.
Since Cash for Clunkers seems to work well, why not extend it to Grandmas and Grandpas?
Win Win?
As for Schaivo, here is a simple point, not all spouses do what is best for their other half. Seems to me if you want a living will, you should at least have it in writing.
Oh, and by the way, 42 GOP Senators voted for this:
“The covered services are: evaluating the beneficiary’s need for pain and symptom management, including the individual’s need for hospice care; counseling the beneficiary with respect to end-of-life issues and care options, and advising the beneficiary regarding advanced care planning.”
…in 2003. That’s from the 2003 medicare prescription Drug Bill (and only applies to terminally ill patients).
ZOMG. The Death panels have been up and running since 2003. No wonder there’s so much Soylent Green on sale at the Stop & Shop.
Hmph. Palin’s playing “first I was for it but now I’m agin’ it” politics. In 2008, her office issued a proclamation that read, in part:
“WHEREAS, Healthcare Decisions Day is designed to raise public awareness of the need to plan ahead for healthcare decisions, related to end of life care and medical decision-making whenever patients are unable to speak for themselves and to encourage the specific use of advance directives to communicate these important healthcare decisions. [...]
WHEREAS, one of the principal goals of Healthcare Decisions Day is to encourage hospitals, nursing homes, assisted living facilities, continuing care retirement communities, and hospices to participate in a statewide effort to provide clear and consistent information to the public about advance directives, as well as to encourage medical professionals and lawyers to volunteer their time and efforts to improve public knowledge and increase the number of Alaska’s citizens with advance directives.
WHEREAS, the Foundation for End of Life Care in Juneau, Alaska, and other organizations throughout the United States have endorsed this event and are committed to educating the public about the importance of discussing healthcare choices and executing advance directives.”
Make of it what you will.
The Alaska resolution you reprint is perfectly fine, and not inconsistent with opposing the sort of protocol in section 1233. The animating principle behind the former is: the patient should do what is good for you and your family. The patient is neither a ward of the state nor its employee. The latter is a government rule embodied in a law that applies all the participants, all of whom depend exclusively on the state for the benefits they receive.
In the former, the context is a wide range of physicians with different understandings of the good life and the nature of medicine. So, if a patient thinks her physician is more Jack Kevorkian than Marcus Welby, then she can find another with which to consult, one that is free to offer her advice consistent with shared values. In the latter, the only considerations that are deemed relevant by the state are utilitarian, with no consideration given to what the patient or physician may think is the true “end” of life. It detaches medicine from philosophical anthropology by state fiat. It treats medicine as if it were a commodity rather than a healing practice.
Remember, the people giving us HR 3200 are the same ones that maintain that the state ought to be neutral on the question of man’s nature and its proper end. So, they support education, with no reference to the proper end of learning. They support “health,” with no reference to what constitutes a person’s well-ordered good. They support “environment sustainability,” and apparently know enough about nature to know precisely how many redwoods belong in the Pacific Northwest, though they don’t know the proper end of man.
Uh…except that the language of the Alaska resolution puts the onus on….wait for it….everyone EXCEPT the patient to provide information related to end of life care for…”patients. . . unable to speak for themselves.”
And I’m not sure where in HR 3200 there is a requirement that a patient follow the advice of anyone. I would love for you to show me. I would also very much like for you to show mere where it says that there is “no consideration given to what the patient or physician may think is the true “end” of life.” As well as where you get that the former context is all these granola-eating physicians “with different understandings of the good life (huh?) and the nature of medicine” but HR 3200 says the opposite.
Seriously, the bill is bad enough that no one needs to make up provisions to fight against the overall bill. Or is it? Is this really the only and best thing that anyone dead set against anything Obama does can come up with to fight against the bill? I get that the irrational fear message of the “death panels” has the huddled masses up in arms…but I really would hope that the substantive discussions here would be, well, a bit more founded in fact rather than fiction.
“Remember, the people giving us HR 3200 are the same ones that maintain that the state ought to be neutral on the question of man’s nature and its proper end.”
Keep the government’s hands off my “proper end”!
“In the former, the context is a wide range of physicians with different understandings of the good life and the nature of medicine. So, if a patient thinks her physician is more Jack Kevorkian than Marcus Welby, then she can find another with which to consult, one that is free to offer her advice consistent with shared values.”
What?? Where in Governor Palin’s proclamation does she talk about such things? You’re completely making up your own context here, interpolating something that just isn’t there.
“To all others, leave the ‘medical professionals’ out of it and simply consult with an attorney knowledgeable in such affairs.”
That’s ridiculous. No attorney could have provided my father with the prognosis for his cancer. It was through medical consensus that my father determined how to spend his final months and what sort of care directives to implement–not the advice of his attorney.