August 19, 2009

Immaturity

Concerning the issue of why, exactly, one should oppose health care reform, let me take on the subject of "Death Panels" and why, although they are a red herring, they reveal something interesting about the issue of how we deal with health care in the United States.


I. Mortality and its Expenses

One day, you are going to die. That isn't a threat, it's a simple fact. That you may find this fact unpleasant does not change its fundamental reality.

Despite all the good nutrition, exercise, premium-quality health care, medicine, and the best efforts of potentially thousands of well-meaning people, one day your heart will stop beating, and you will die. So far in human history this has happened to every human being who has ever lived. (Yes, even Jesus -- even within the Christian religion, Jesus actually dies on the cross before he is resurrected). It will happen to me, it will happen to everyone that I love, it will happen to you, and it will happen to everyone you love. It is inevitable. No matter what else you may think about human nature, mortality is the one thing that all human beings unquestionably have in common.

Readers, I hope for all of your sakes that this transition is long-delayed and that each of you have long, happy, pleasure-filed lives before this happens to you; I hope that when this change does come (as it inevitably will) it is very quick and completely painless. But it will happen. And you would be deeply foolish to think otherwise.

Now, you may think, "My death will not have any significant consequences." Hey, maybe you're even right. Maybe you have no friends, maybe no one loves you and no one will mourn your passage. That's probably not true, of course, but maybe it is in your case.

Nevertheless, your death will have consequences on the body politic. If nothing else, someone is going to have to clean up your corpse and whatever bodily fluids leak out of your body in between the time you expire and the time it is found. Whoever finds you is unlikely to be used to contact with dead bodies and therefore will experience a degree of psychological shock. You're probably going to smell bad, too. A doctor will have to examine your corpse and verify that indeed you are dead. A public official such as a coroner will have to handle your body and issue paperwork documenting your death. Someone is going to have to dispose of your body in some way, either by burying it or embalming it or cremating it. Unless you have no family and no friends at all, someone will probably want to have a memorial service of some kind or another in your honor, if only to ease their own grief at your death.

Most of these things cost money. All of them divert resources, whether financial or otherwise, from other uses.


II. Planning for Death

For the most part, we treat death as a medical condition in this country, one which as a rule of thumb we devote resources to avoiding. Given the inevitability of death, this is kind of like the moral logic of an airplane -- the device is simply too big to stay aloft forever and eventually it will run out of fuel, so at some point, it's going to have to land. But that doesn't mean we simply allow it to crash whenever something goes wrong. So too with preserving human life.

Because we as a society have decided that life is worth saving, we try to save lives. So we spend money -- public money if need be -- to keep people alive regardless of who they are. We send paramedics out to revive people who experience cardiac arrest. We train our doctors extensively in ways to keep people alive in despite disease and injury. We invest billions of dollars and devote a large segment of our economy to finding and delivering ways to keep people alive in the form of "medical care." Our scientists devote tremendous resources and intellect into creating medications and ways of treatment to preserve life in the face of daunting challenges which, without the benefit of scientific medicine, would take massive amounts of life at early ages.

To do otherwise would deeply offend our collective sense of morality.

We have created a financial product called "life insurance." If you think there might be someone still alive after you die who would be adversely affected by your death -- say, a spouse or a child who will now have to do without the financial support you provide -- you can buy a product while you're alive that will provide for the financial equivalent of the support you would have given had you lived. This seems to me to be a deeply moral and compassionate thing to do, particularly given the inevitability of your death.

No one thinks life insurance salespeople are doing something morally wrong by selling their product. Not everyone buys it, of course; not everyone is ready to admit that they are mortal and that their death will cause pain and suffering to those whom they love. And of course money is a poor substitute indeed for the actual love and companionship of someone. But death is inevitable, so that love and companionship will one day be gone. When you accept that fact, life insurance starts to look like something you ought to seriously consider spending your money on.

What's more, the time, place, and manner of your death is utterly unpredictable. For some, there are factors that may shift some of the probabilities; a history of heart disease in your family, for instance, or an occupation that requires you to drive more than the average person. Actuaries and underwriters make their living figuring that sort of thing out.

For some of us, nothing anyone can do will prevent it. For others, threats to life will arise which modern medicine can combat. Two dramatic examples:

Contracting bubonic plague used to be a pretty certain death sentence. It's still a serious and life-threatening medical condition. But thanks to the development of antibiotics and other kinds of medical treatment, if the plague is identified early enough after a patient contracts it, the disease is survivable.

I've met people -- and you probably have too -- who have had heart attacks severe enough that they actually died. Their hearts stopped completely; their brains ceased to function; their bowels relaxed; their lungs no longer moved; blood began to respond to gravity instead of pressure. Then, someone else performed CPR and revived them. This happens so frequently in contemporary life that we do not consider it all that remarkable anymore.

This is the power of modern medicine. It can ressurect the dead. It has reduced a plague which once felled between a third to a half of all human beings in the Eurasian landmass in a period of three years to a serious but curable disease. But to do these things requires the intelligent, advance deployment of resources. Expensive resources.


III. Economic Choices About Death Are Mandatory

To survive the plague thanks to modern medical treatment requires that a patient spend a long time in a hospital, where the patient consumes huge amounts of antibiotics and donated blood. At what ultimately amounts to tremendous economic expense and a large devotion of the labor of doctors and nurses who could have spent their time treating other patients with other kinds of problems.

To perform the miracle of resurrection through CPR, an investment in training someone in the technique must be made. That this person then be summoned to the scene of a cardiac arrest and perform this service. All of this takes an investment of money and resources into putting this person on call and having a delivery service like an ambulance available to get the victim and the resuscitator to the same place soon enough that the treatment will be effective. That, in turn takes money. Meanwhile, the resuscitator could have been doing something else for someone else.

Somebody, somewhere, somehow, decided that the plague victim was worth the expenditure of those resources and someone else was not. Somebody, somewhere, somehow, decided that the cardiac arrest victim was worth the expenditure of those resources and someone else was not. Who was that somebody? How did they make that decision?

Given that we apply our considerable technological and economic power to preventing and in some cases even curing and reversing death, chances are good that unless you have a complete cardiac failure in your sleep or some very sudden act (such as violence or a vehicular collision) ends your life, you will go through a period of time in which medical and financial resources are expended to keep you alive. Those resources are scarce, not plentiful. As I've written before, we don't have enough of those resources -- even in the world's most technologically advanced and wealthiest society -- for everyone to have all the health care they could possibly want.

So somebody, somewhere, somehow, has to decide that somebody doesn't get those resources. That is a life-or-death decision. It is also by definition an economic decision -- it involves the allocation of a scarce resource.

The best person to make that sort of decision, I submit, is the person whose death is the subject of the decision. For the future decedent to make a decision about when and how death will occur is something that requires advance planning. When the situation is at hand, quite often the would-be decedent will not be in a position to make that decision. Thus, the law steps in and we have things like living wills, through which a person can state in advance of an emergency what they would like to have happen if something terrible goes on.

But not everyone wants to do this. Just like not everyone wants to buy life insurance. This is an unpleasant task for many people because it involves confronting one's own mortality. It involves contemplating one's own death and the prospect of what will happen to the people one loves and supports afterwards. I find the idea of considering what life would be like for The Wife after my death (should I predecease her) very unpleasant. I imagine she finds the idea of considering the converse situation unpleasant, as well. That is, however, part of what it is to love someone in a mature way. And dealing with this issue is a hallmark of maturity.

No one's forcing you to buy life insurance. No one will force you to execute a living will. You are free to not do these things. You are free to abdicate that decision-making process to -- well, to someone else. Maybe that person will be your spouse or your child. Maybe it will be your doctor. Who knows? Maybe it will even be a bureaucrat or an insurance adjuster.

If you don't decide how to handle your own death, someone else will. That decision will be inherently economic.

IV. What's Really On The Table In Washington

Someone (Sarah Palin or someone working with her) came up with the idea that the "Obamacare" reform would involve someone making this inevitable economic decision. Perhaps this person ignored the simple, inevitable fact that such an economic decision is an unavoidable consequence of, well, life.

This "death panel" nonsense that is polluting our debate about health care reform is based on language in the primary health reform bill in Congress that would require doctors to periodically discuss end-of-life care planning with their patients. This would, I presume, involve doctors explaining what living wills are, what hospice care is, and that Medicare (or whatever we substitute for it) will pay for some of this stuff. Maybe it even will go so far as to have the doctor say to the person, "If you don't decide in advance what you want done to keep you alive, someone else will have to make that decision for you."

That's not a "death panel," or if it is, it's hardly an innovation. That's the status quo, my friends.

But that's what is being used to scare people away from even considering the idea of reforming the quickly-bankrupting public medical insurance system upon which, like it or not, all of us rely. Even if you have private insurance, chances are very good that at some point in your life (often after age 65), that private insurance will piggyback on Medicare. Moreover, all private insurance payments are roughly indexed to the discounts on the face value of medical services charged by providers like hospitals and doctors. It is routine for Medicare to pay 25% of the face value demanded for many services, and private insurance follows this lead.

Now, what's on the table in Washington is described in an article published today by the until-now-I-thought-he-was-sane Nat Hentoff:
A specific end-of-life proposal is in draft Section 1233 of H.R. 3200, a House Democratic health care bill that is echoed in two others that also call for versions of "advance care planning consultation" every five years — or sooner if the patient is diagnosed with a progressive or terminal illness.

As the Washington Post's Charles Lane penetratingly explains (Undue influence," Aug. 8): the government would pay doctors to discuss with Medicare patients explanations of "living wills and durable powers of attorney … and (provide) a list of national and state-specific resources to assist consumers and their families" on making advance-care planning (read end-of-life) decisions.

Significantly, Lane adds that, "The doctor 'shall' (that's an order) explain that Medicare pays for hospice care (hint, hint)."

But the Obama administration claims these fateful consultations are "purely voluntary." In response, Lane — who learned a lot about reading between the lines while the Washington Post's Supreme Court reporter — advises us:

"To me, 'purely voluntary' means 'not unless the patient requests one.'"

But Obamas' doctors will initiate these chats. "Patients," notes Lane, "may refuse without penalty, but many will bow to white-coated authority."
Well, of course they will. People trust their doctors, and if their doctors say, "Maybe you should consider hospice care," then I hope they will.

Seriously, what is really objectionable about this?

Frankly, if I look to my medical care providers for nothing else, I'd want hospice care for my last days. I would a doctor to take away the pain and a counselor to ease the fear of my imminent non-existence. And just as important, I want that counselor to help the people who love me to prepare for their grief. I can think of no more valuable service that could be rendered to a patient than this form of extreme unction.

Well, that, and if you're going to have a memorial service or a wake or something for me, I think it would be great if you did it while I was still alive to enjoy it. It doesn't have to be morbid -- hell, you can roast me.

What, then, is the moral objection to a policy of having doctors counsel patients that this service is available? The only objection that I can fathom is that someone might think that "Gee, if death can be made painless, maybe that's the option for me." If someone is going to think that, then the issue is psychological because that's the functional equivalent of suicidal ideation. As much as I would want hospice care for my final days, that doesn't mean I'm eager to die. To confuse wanting an eased transition to non-existence with a desire for that transition to take place is ... well, it's baffling.

Is the objection that, while maybe I'm willing to accept hospice, you have a moral objection to paying for it? Too bad. The government pays for all sorts of things that all sorts of people have moral objections to. You get a vote, and if you are in the minority, you get to challenge the Constitutionality of the majority's decision, and if you lose that, then you get to tolerate the policy being implemented.

So the only real issue here seems to me to be that someone thinks that health care is dealing with the issue of death at all. As if death doesn't exist, or as if medicine and death were somehow opposites. They aren't. Death is the end of life. It should receive as much thought and care and resources as any other phase of one's journey through a medical crisis.


V. Don't Be An Ostrich

If we're going to reform health care at all, end-of-life care should be a piece of that puzzle. To use this as a scare tactic strikes me as the essence of the same kind of immaturity that leads people to refuse to consider buying life insurance. Sticking your head in the sand about it won't make the issue go away. The issue is this:

One day, you are going to die. Who benefits from the government ignoring that fact?Stumble Upon Toolbar

2 comments:

wetblanket said...

Excellent post, thank you.

While I'm confused about what would be the best way to handle health care, the so called "death panels" prattle is really the most egregious form of "whistling past the graveyard" that not only distracts from rational discussion, but also allows those involved to ignore the inevitable.

Thanks again.

Transplanted Lawyer said...

It's not an easy issue and there are no good solutions that I've seen. The least bad idea in Congress that I've come across is the Wyden-Bennett proposal, S. 391.