Topic: Health Care
Euthanasia in the Health Care Plan - an Analysis. Concerning euthanasia and "death panels" in Obama Health Care legislation.by Lonnie Dalton
(libertarian)
Friday, August 28, 2009
"Death Panels" and "Euthanasia" have been a topic of discussion lately due to the Obama health care plan dominating the news. Perhaps you've received alarming e-mails on the topic and are wondering what really is happening. In my case I received e-mails with the headlines "EUTHANASIA FOR THE ELDERLY" and "WASHINGTON POST CONFIRMS GRANDMA FACES EUTHANASIA UNDER OBAMACARE." This became my occasion to research the topic. While some of the communications of the concerns indeed have taken on a bit of Jerry Springer flavor, there is true (if more subtle) cause for concern. My thoughts follow.
Inflated (Sensational?) Headlines
First, the headline "The Washington Post Confirms Grandma Faces Euthanasia under ObamaCare" seems inaccurate due to hyperbole. By my interpretation, "The Washington Post" didn't confirm anything. The headline implies that the news organization went investigating and fact checking, and their news division has uncovered "the truth." But the article was not a news story. Rather someone on their editorial staff wrote a column - "Undue Influence: The House Bill Skews End-of-Life Counsel," by Charles Lane, dated August 8, 2009. 1
Further, the e-mail's headline makes it seem that there are definitely euthanasia provisions in the bill. Yet Lane finds no such express provisions. In fact, he points out an express ban against Medicare paying for services that promote euthanasia (more on that later). Instead, Lane merely sees requirements of the bill that might result in added pressure for the Medicare patient (or family) to end life-saving treatment. You can question whether the government should ever be the (added?) reason someone might be pressured towards such "options," but even that is a far cry from what this headline implies. "Grandma Faces Euthanasia" makes it seem that the carrying out of a morbid policy against the elderly is a foregone conclusion, rather than it being what the columnist sees as the mere increased possibility that someone might be pressured. The same headline also seems to imply an involuntary aspect, but by the author's interpretation (and mine) there is pressure but the choice is still in the hands of the patient or the family.
To their credit, the authors of the e-mails, despite their screaming headlines, were more calm, collected, and accurate in the e-mail body. For instance, they referred to Lane as a Post editorial board member, and specifically and accurately state Lane's nuanced concerns about the bill.
The Roots of the Controversy
At the heart of this matter is Section 1233 of the health care bill drafted in the House.2 This section would amend Section 1861 of the Social Security Act (42 U.S.C. 1395x). In so doing, "practitioners" would now be paid to administer "advance care planning consultations" every five years or more frequently if the patient's health condition significantly changes (Lane correctly states that the consultations can be done upon a terminal diagnosis, but the exception is much broader than that).
A "practitioner" is defined as a physician, or as a nurse practitioner or physician's assistant "who has authority under state law to sign orders for life sustaining treatments." More on those orders later.
The concern according to the Post's Lane is tied to the fact that doctors would be paid by the federal government to administer end-of life counseling ("advance care planning consultations"), and will administer that counseling if a patient has a significant illness. Regarding this "advance care planning," the bill specifically allows that this counseling can include the "formulation" of an "order regarding life sustaining treatment." Despite its name, such orders are not limited to "life sustaining" treatment. Rather, the bill says that through an order, a patient might limit some or all of their medical treatments (through a "pull-the-plug" agreement, refuse treatment agreements, et cetera). Since such an order can be discussed, the concern is that practitioners WOULD discuss them, particularly emphasizing, favoring, and recommending that the patient sign an order that would limit or stop medical treatment. Due to an attending physician's position of authority and trust, any argument they make is likely quite persuasive if made forcefully. But in this situation, the payment incentives and the fact that the doctor is in a fashion representing Medicare, may mean they pressure the patient more vigorously, in order to further the goal of saving Medicare money. And when does heavy pressure on a weakened patient who has lost his doctor's full medical support turn into practical coercion in such cases?
Compounding the risk is the fact that the five-year period between such counseling is illusory. The exception guts the rule, so that counseling may occur upon significant changes to the patient's health condition, from diagnosis of chronic disease to a terminal diagnosis, and many points in between.
I've seen in some commentary the idea that little could seem less harmful than a senior asking his or her physician about end-of-life planning and the doctor obliging.3 When that is what happens, it would seem fairly harmless (ignoring the incentives the doctor has as an interested party). Yet there is no provision that says that the patient must initiate the conversation – practitioners can initiate such discussions, and will have the financial incentive to do so. This is likely the source of some people's concerns, although incorrectly stated, that these discussions are mandatory - a patient could have the discussion pushed on them by an overbearing doctor who won't take no for an answer. But in the literal sense, a doctor has no right to force a patient to listen or to force them to sign any order.
While there is broad possibility for this "pressuring," it is true that the practitioner is not required to perform the counseling. Even when the special cases arise allowing advance care planning because the patient's health condition has changed – again, the pracitioner "may" conduct the consultations. And the "formulation of an order regarding life sustaining treatment" is not a mandatory part of the consultations. But given that the practitioners would be paid per consultation, and at a much higher frequency than once every five years per patient (as explained above), it seems the rule would be that elderly patients could be subject to counseling (and therefore potential pressuring) much more frequently than once every five years. Many doctors would take on such counseling as a matter of course and an easy opportunity to earn some consulting fees.
A concern would be whether routinely being de facto representatives of Medicare and repetitively repeating the mantra of saving money for the sake of the country might over a period of time pull doctors' viewpoints as a whole away from the Hippocratic Oath and towards a viewpoint that more closely resembles that of some of the figures behind this "health care reform movement" - that health care costs should not be wasted upon those who can no longer be "participating citizens."4
It is true that costs of care enter into the equation every day in every hospital, but do we want to institute a massive central plan that not only tolerates these "financial cost over human value" decisions, but embraces them?
Recall the mention earlier of a law banning Medicare paying for services the purpose of which are euthanasia. But that provision seems to be no shield here, for the argument is not that euthanasia is the PURPOSE, but rather that its increased likelihood is an EFFECT of the bill.
Another point worth mentioning is a discussion of terminology. Here I've used "euthanasia" in a way some people may not consider. For some people, the term itself has such a negative connotation that it even seems to come complete with a implication that euthanasia is by its nature involuntary or forced. Euthanasia as I'm using it and as generally accepted is a neutral term and doesn't take into account whether the individual consented. I simply mean it as a hastening of death due to a lack of otherwise available medical treatment.* In the context of the bill, any increased euthanasia would be the result of at least the purported desire of patients or family members of those patients acting on their behalf.
But that is the question, isn't it? Would increased euthanasia result because individuals are educated more on how to plan their lives and estates in advance and with that comfort feel free to release themselves from their physical pain? Or would it be because they'd been pressured to believe their lives were not worth living for themselves or their family, and that they were burdening their country?
Certainly nothing in black and white in this bill requires or suggests to doctors or other practitioners that they must "inform patients of euthanasia options to keep costs down." The valid argument in this case is simply that the bill as written would result in an increased likelihood that vulnerable or non-assertive people would be pressured into euthanasia (and the increased possibility applied to a mass scale would result in real cases of "coerced" euthanasia that otherwise would not have occured). The other argument is that over a period of time with these proposed policies in place, perhaps health care would take on a decidedly intolerant view of the unhealthy.
As often is the case, the truth here is a little more subtle than the screaming headlines (although that does not excuse the writers of the screaming headlines!). But exaggerated headlines don't mean there is not an underlying concern. As with many arguments against government programs, the originators of the policies don't see grave consequences, either because they don't WANT to see them or because they are unable. Worse, they often don't acknowledge the problems when someone else points them out. They're too wrapped up in their "solution" and see only the goals they think it can accomplish. The mortal flaws that are the negative consequences and effects of their plans are so often invisible to them. Instead, the opposition is deemed as evil or ignorant for not buying into their vision.
But then again, if big government types were inclined to see the problems that government meddling causes... it is doubtful they'd be big government types.
Lonnie Dalton
*I have not considered whether affirmative acts of euthanasia are affected by this bill, but at this point and upon reviewing the bill for the intital purposes, I don't believe it is a major concern.
1. Lane, Charles. "Undue Influence: The House Bill Skews End-of-Life Counsel." Washington Post. 8 Aug. 2009. Web. 27 Aug. 2009. <[link edited for length]>.
2. "House Resolution To Provide Affordable Quality Health Care for All Americans, and to Reduce the Growth in Health Care Spending, and for Other Purposes" U.S. House Committe on Education and Labor. 14. Jul. 2009. Web. 28 Aug. 2009. <[link edited for length]>.
3. Ashford, Kenneth. "Sarah Palin Adds Commentary About 'Death Panels' [Update: Palin Supported the Same Provisions She Now Decries as Euthanasia]". The Seventh Sense. 13 Aug. 2009. Web. 28 Aug. 2009. <[link edited for length]>.
4. McCaughey, Betsy. "Obama's Health Rationer -in-Chief: White House Health-Care Adviser Ezekiel Emanuel Blames Hippocratic Oath for the 'Overuse' of Medical Care". Wall Street Journal. 27 Aug. 2009. Web. 28 Aug. 2009. <[link edited for length]>
An aside on Sarah Palin
Incidentally, my research on this topic has led me to a Sarah Palin post on her facebook page. I've not paid much attention to Palin, but one cannot help absorb through the ether the continual putdowns of her abilities and intelligence. I've never known enough to argue against those characterizations (and besides, I've had the hots for Tina Fey forever, so whatever gets her on screen more is something of which I'm quite tolerant). Yet, as to this particular post, I can objectively say that it is quite cogent and articulate and correct. Maybe this is a massive exception for her, but if this will be her standard operating procedure for public debate from here on, then more power to her. And if this has been her general competence level all along, then I apologize for believing the naysayers, to the extent I paid attention.
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The views expressed in this
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