This is a question that has gotten a lot more attention than it deserves. Let’s take a look at it. A “death panel” would have to be a number of people (panel) that is empowered to take an action or to withhold it, the result of which would be that the person in question dies. That brings us now to two questions: a) are there any such panels and b) is there any provision in the Patient Protection and Affordable Care Act (Obamacare) that facilitates the death of patients?
Are there death panels?
Yes. Of course there are. Not like these. Let’s try to imagine what it would be like if there were not. It would mean that there were no medical procedures that “cost too much.” For the very rich, of course, this is often true. If a procedure were available that extended a rich man’s life at the cost of a million dollars a day and he wants to pay the million dollars a day, he will be treated.
If that same procedure were recommended for a poor woman, the question of cost would come up. If the poor woman is insured, the insurance company will have to say yes or no.
If not, some payer of last resort will be looked for. Back when there were no procedures that cost a million a day, families sometimes pitched in, but we are out of the range of family resources here. In Oregon, I have seen tearful mothers begin media campaigns for contributions that will save the life of a child, only to see the child die before enough money was contributed. If there were some way to make it funny, it would be a terrific TV game show.
Here’s the truth. If there is a medical procedure to be done, someone is going to have to be paid to do it. Any group of people who refuses to pay the cost of a procedure, is a “death panel.”
2. What does Obamacare have to do with death panels?
Nothing. Let’s start the question at another point. Do you think that elderly people ought to have the right to make decisions about how their last days will be managed? Me too. If they don’t decide when they are able, someone will decide for them when they are no longer able.
Brief Excursus: The word I always use for this is “agency,” I want to be the agent—that’s Latin for “the one who acts”—in my own life. There is a nastier form of this consideration that uses autonomy instead. I am a big fan of autonomy when it is my own autonomy we are considering, but I am not such a big fan of the word anymore because “autonomy” is too close to “heteronomy.” Someone is going to “be the law” in a situation—that’s the nomos part. It will be me (auto-) or someone else, (hetero-). My hesitation about the word autonomy, considered in the light of its alternatives, is that it raises the question of alternatives. I don’t want that question raised. I want it presumed and “agency” does that for me. Incursus resumes here.
Presumably a woman and her husband will sit down with a knowledgeable person to talk about how they want their last days handled. Making my own decisions about that is important to me and having the advice of a doctor can help a lot. Question: who is going to pay the doctor for spending his or her time that way? Here is a little cut from Wikipeda, every piece of which, with the exceptions of the names of the cosponsors, I know to be true.
A bill to provide for reimbursement every five years for office visit discussions with Medicare patients on advance directives, living wills, and other end of life care issues was proposed by Rep. Earl Blumenauer (D-OR) in April 2009—with Republican cosponsors Charles Boustany (R-LA), a cardiovascular surgeon, Patrick Tiberi (R-OH), and Geoff Davis (R-KY). The counseling was to be voluntary and could be reimbursed more often if a grave illness occurred. The legislation had been encouraged by Gundersen Lutheran and a loose coalition of other hospitals in La Crosse, Wisconsin that had had positive experiences with the widespread use of advance directives.
Earl Blumenauer is a very good congressman, but I take special pleasure in noting his contribution to this issue because he is the only member of Congress who could greet me by name if we met on the street. So the answer to the question of who pays the doctor to be a part of this conversation is: Medicare. As important as these conversations are—they are the only way to guard agency and understanding at the same time—the doctors aren’t going to do them for free and they shouldn’t have to. So the “Obama death panel” controversy, from this standpoint is, “Should the doctors be compensated for their work in helping people insure that their wishes are honored when they are no longer able to insist on them?”
You don’t have to be liberal to like the sound of that.
The argument against this provision of Obamacare is that it could be abused, that “panels of bureaucrats” (Sarah Palin’s phrasing) would coerce elderly people to “choose” to have the government kill them. Any discussion can be perverted. I know that. Even teacher parent conferences can be perverted. I have been the student, the parent, and the teacher in those conversations. When the common purpose uniting the members of the conference falters, everyone has a “me first” substitute. I remember that most vividly when I was the child in question.
So here are two questions. What will happen if we do pay doctors to be a part of these discussions and what will happen if we don’t? Remember the reference, above, to LaCrosse, Wisconsin? Here’s why that is there. You can see the whole piece from Forbes Magazine here.
Imagine a town of 50,000 Americans where 96% of those who die have signed an “advance directive” codifying their conscious decisions about how they would like to die. This is quite an accomplishment given we haven’t been able to move the needle at a national level beyond 30% over the past 30 years. By definition every possible polarized constituency in this town– conservative and liberal, religious and secular, Republican and Democrat, rich and poor– agree on one of the most divisive political and social issues in America. Welcome to La Crosse, Wisconsin– a Midwestern everytown USA that has managed to transcend Sarah Palin’s death panel rhetoric not only to become the “cheapest place to die in America.” But, more importantly, they have transformed the entire “tenor of care” for end-of-life planning.
96%! How did they do that? By talking about it together. What a concept. And the effect on medical costs of this plan, which, in LaCrosse, is called “Respecting Choices Advance Care Planning?”
Nationally, the average cost for a patient’s last two years of life is $26,000 (in some hospitals average costs run as high as $65,000) the average cost in La Crosse, is just $18,159.
The “death panels” charge was a low blow. PolitiFact, which makes its living checking such charges, named it their “Lie of the Year.” It’s bad and everyone who participated in it should be ashamed. But the real cost, beyond the moral theater of it, is that we are not doing, nationally, what they have already achieved in LaCrosse. Agency is respected. Conversations are held. Money is saved.
Which of those three outcomes does anyone want to object to?