Live or Let Die

By Philip Klein on 8.14.09 @ 6:09AM

Somewhere in between warnings of a "death panel" and promises of a utopian medical future, there is an honest discussion to be had about ethics, human mortality, and the role of government in our nation's health care system.

A provision within the House Democrats' health care bill that would create a new Medicare benefit paying for senior citizens to talk to a doctor or nurse about how to prepare for end-of-life medical decisions has emerged as one of the most controversial elements of the legislation. But before exploring the broader implications, it's important to be clear about what the notorious section 1233 of the "America's Affordable Health Choices Act" does and does not say. Despite claims to the contrary, the provision (described in detail on pages 424 to 434 of the bill under the section "Advanced Care Planning Consultation") does not create a "death panel," mention euthanasia, or mandate that senior citizens participate in counseling sessions.

Instead, the bill would reimburse Medicare recipients for one session every five years, and potentially more if their health deteriorates considerably or they are admitted into a nursing facility. Such sessions, as described in the bill, would cover topics as benign as explaining the type of services that are available under Medicare, to thornier issues, such as living wills and creating medical orders that would specify what type of treatment patients would want to receive to sustain their lives if they can no longer communicate their wishes.

Seniors would be given the option of creating a medical order that would describe, "the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems; the individual's desire regarding transfer to a hospital or remaining at the current care setting; the use of antibiotics; and the use of artificially administered nutrition and hydration."

Despite the ominous sound, there is a pragmatic basis for such a provision. In 2005, the Terri Schiavo tragedy became a heated national political issue, because an accident left the Florida woman incapable of expressing whether she wanted to be kept alive with the aid of life-sustaining technology, and there wasn't any clear record of what her own wishes would have been. This uncertainty led to a dispute among her relatives that sent the issue into the courts, and ultimately, the halls of Congress and the White House. While Schiavo was a young woman when she suffered her accident, at least conceptually, the controversial provision of the House legislation seeks to avoid such circumstances among the elderly by paying for them, if they choose, to learn more about how they can spell out their wishes in advance.

With that said, the provision has to be viewed within the larger context of the changes that President Obama envisions for the health care system as a whole. Though he denies it now, Obama was once a proud advocate of a single-payer system in which government is the sole purchaser of health care. Throughout the health care debate, he has cited erroneous statistics to promote the idea that government-run systems get better value for their health care spending. And through a web of subsidies, mandates, regulations, and the creation of a government-run plan, Obama hopes to make America function more like the foreign health care systems he prefers. Those systems do not control costs by using magic wands, but by rationing care to the sick.

Britain, for instance, has a panel of experts called National Institute for Health and Clinical Excellence that performs cost-benefit analysis to help determine what sorts of treatment the government will pay for, and for whom. According to a report in the New York Times, NICE "has decided that Britain, except in rare cases, can afford only 15,000, or about $22,750, to save six months of a citizen's life."

NICE was one of the inspirations for Tom Daschle's vision for a Federal Health Board, an idea Obama praised before originally tapping Daschle to lead his health care push. The idea for an expert panel has already manifested itself in the form of Obama's Federal Coordinating Council for Comparative Clinical Effectiveness Research, created by the economic stimulus bill.

While Obama argues that his council will just be providing expert research to doctors and patients, if you read Tom Daschle's book Critical: What We Can Do About the Health-Care Crisis, in the context of describing a Federal Health Board, he outlined how government could compel wider adoption of such a body's recommendations. For instance, Daschle explained, there could be a requirement that all government programs would have to abide by its recommendations and that requirement could extend to any private insurer participating in the government health insurance exchange. And as Daschle wrote, "Congress could opt to go further with the Board's recommendations. It could, for example, link the tax exclusion for health insurance to insurance that complies with the Board's recommendations."

And while the bill doesn't include any provision about euthanasia, which remains illegal in almost every state, the idea of government subsidized suicide is not as far-fetched as it sounds. In Oregon, for instance, the state's health care plan sent a letter declining to pay for cancer patient Barbara Wagner's expensive chemotherapy drug, but offered to cover the cost of doctor-assisted suicide. This was not an isolated incident, as similar letters were sent to terminally ill patients throughout the state last year.

This, of course, is the inevitable result of thinking of health care as a collective good that should be allocated by the state. If health care operates on a global budget, then it becomes a zero-sum game in which providing more care to one patient means depriving another patient of care. And suddenly life and death health decisions evolve from something that is between you, your faith, your family, and your doctor, into highly-politicized issues that are the business of government and your fellow taxpayers.

Instead of being honest about the natural tradeoffs involved in trying to "bend the health care cost curve," Obama has promised Americans a utopia in which everybody is covered, quality improves, our debt actually decreases over time, only the very rich have to pay a tiny amount of extra taxes, and there will be no rationing of care. As Obama promised this week while in full salesman mode, "You will have not only the care you need, but also the care that right now is being denied to you -- only if we get health care reform."

But Obama's disingenuousness doesn't get conservatives completely off the hook, either. The right has been pushing back hard against the specter of government cutting off Medicare beneficiaries in their final days. Even if the House legislation did make that happen, however, is it clearly more ethical for conservatives to argue that we should dedicate an effectively unlimited amount of resources to treat those who are terminally ill or in a comatose state, while depriving others who are not old or sick or poor enough of any form of government benefits?

It's an ugly issue that nobody wants to bring up precisely because of the reaction we're seeing right now. But the dilemma will only become more pronounced with entitlement spending out of control, the development of life-preserving technologies expanding, and Baby Boomers set to retire. The reality is that we do not have a free market for health care in the United States and that government is responsible for 46 percent of health care spending. Nobody wants to be the heartless person who puts a price on human life and argues that we cannot afford to give a patient treatment that will mean the difference between death and survival. And certainly, nobody wants the person making that decision to be a government bureaucrat. But if conservatives believe in providing unlimited end-of-life care, then it necessarily means some combination of higher taxes, greater debt, or substantial cuts in other government services. In the coming years and decades, this reality will create friction between the desire of conservatives to protect human life in all of its forms and to limit the growth of government.

In that sense, the debate we're having over the implications of end-of-life counseling is just a harbinger of problems to come, which Obamacare would only exacerbate.


Philip Klein is The American Spectator's Washington correspondent.

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