September 9, 2009

Death Panels -- Considering and Answering Palin's Real Fears

Sarah Palin just expounded further on her fears about "death panels." Let me first show her letter (below), then I will recommend a specific way to respond to the main fear Palin pinpoints.

Senator Reverend Ruben Diaz Chair, New York Senate Aging Committee Legislative Office Building Room 307 Albany, NY 12247
September 8, 2009

RE: H.R. 3200: America's Affordable Health Choices Act of 2009 and Its Impact on Senior Citizens

Dear Senator Diaz,

Thank you for asking me to participate in the New York State Senate Aging Committee's hearing regarding H.R. 3200, "America's Affordable Health Choices Act of 2009." You and I share a commitment to ensuring that our health care system is not "reformed" at the expense of America's senior citizens.

I have been vocal in my opposition to Section 1233 of H.R.3200, entitled "Advance Care Planning Consultation."[1] Proponents of the bill have described this section as an entirely voluntary provision that simply increases the information offered to Medicare recipients. That is misleading. 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."[2] During those consultations, practitioners are to 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.[3]

To understand this provision fully, it must be read 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."[4] 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 one commentator has noted, 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?"[5]

As you stated in your letter to Congressman Henry Waxman of California:
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.[6]

It is unclear whether section 1233 or a provision like it will remain part of any final health care bill. Regardless of its fate, the larger issue of rationed health care remains.
A great deal of attention was given to my use of the phrase "death panel" in discussing such rationing.[7] Despite repeated attempts by many in the media to dismiss this phrase as a "myth", its accuracy has been vindicated. In the face of a nationwide public outcry, the Senate Finance Committee agreed to "drop end-of-life provisions from consideration entirely because of the way they could be misinterpreted and implemented incorrectly."[8] Jim Towey, the former head of the White House Office of Faith-Based Initiatives, then called attention to what's already occurring at the Department of Veteran's Affairs, where "government bureaucrats are greasing the slippery slope that can start with cost containment but quickly become a systematic denial of care."[9] Even Washington Post columnist Eugene Robinson, a strong supporter of President Obama, agreed 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."[10] And of course President Obama has not backed away from his support for the creation of an unelected, largely unaccountable Independent Medicare Advisory Council to help control Medicare costs; he had previously suggested that such a group should guide decisions regarding "that huge driver of cost . . . the chronically ill and those toward the end of their lives...."[11]

The fact is that any group of government bureaucrats that makes decisions affecting life or death is essentially a "death panel." The work of Dr. Ezekiel Emanuel, President Obama's health policy advisor and the brother of his chief of staff, is particularly disturbing on this score. Dr. Emanuel has written extensively on the topic of rationed health care, describing a "Complete Lives System" for allotting medical care based on "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."[12]

He also 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."[13]

Such ideas are shocking, but they could ultimately be used by government bureaucrats to help determine the treatment of our loved ones. We must ensure that human dignity remains at the center of any proposed health care reform. Real health care reform would also follow free market principles, including the encouragement of health savings accounts; would remove the barriers to purchasing health insurance across state lines; and would include tort reform so as to potentially save billions each year in wasteful spending connected to the filing of frivolous lawsuits. H.R. 3200 is not the reform we are looking for.

Thank you for calling attention to this important matter. I look forward to working with you again to ensure that we keep the dignity of our senior citizens foremost in any health care discussion.


Governor Sarah Palin


I just had a further insight on exactly what Palin and many people actually do fear when they speak of "death panels."

A real, actual fear.

First, let me point out I myself will likely take advantage eventually of any possible consultations about what kinds of treatment and care I could receive in old age in varied situations, so as to lay out under what conditions I would like what kind of care, and under what conditions I would not want certain kinds of treatments.

But part of the reason such a consultation with my doctor will someday be valuable to me personally is that I do not have an overwhelming fear of death. Instead, I am more afraid of having a lingering, uncomfortable hospital intervention where the outcome of dying is clearly inevitable.

Like Senator Kennedy recently, I'd rather be sailing, sitting at home, eating ice cream, and spending quality time with friends and family as the end approaches.

Sure I have some ordinary fear of dying, but not a strong, active fear that takes over and dominates when I think on dying. My life experiences have moved me past that.

So I actually see that kind of consultation as a positive -- it will give me more control of my own going, in my own way, according to what I like and value....

But...if I did have a strong, powerful fear of death -- which is a very commonplace human condition -- I'd have an entirely different feeling about such a consultation.

I'd dread and fear even the consultation, and it would discomfort me greatly to contemplate even the consultation.

I'd feel that even the suggestion of such a consultation was ominous and threatening.

Then I'd likely feel that it would be wrong, horrible, to subject people to such a consultation if they were not ready for it.

So I'd want such consultations to be entirely voluntary.

Just like they were written in the proposed legislation -- voluntary.

But there's more to this....

I think I can vaguely appreciate Palin's own feeling that some people would feel pressured even by talking with their own doctor -- as if just the options where they could opt for less heroic care would create a kind of social pressure to choose other than what they would really want. feel that way myself -- pressured -- I'd have to feel less autonomous, less able to form my own opinions and know what I think and feel independently of others.

But there are people who feel swayed and pressured by others' opinions quite easily I understand.

So I'm guessing at how they would feel....

They might feel pressured enough just by a suggestion alone to actually ignore their own preferences, in a instance where a doctor communicates incompetently or oddly enough to not phrase options in a neutral way.

Therefore, it would make sense for any such consultation initiation to also be voluntary -- only initiated by the patient themselves, and not by suggestion of their doctor. This would avoid some instances where an individual that has little sense of self-determination could end up choosing wrongly for themselves.

Though I expect this was indeed the original intent behind the proposal -- that such consultations be genuinely 100% voluntary in *every* sense -- it could be made explicitly clear in any such proposal that only a patient could initiate even the option of having such a consultation.

There could be no phone call or letter from any provider or insurer to ask whether the patient wanted such a consultation.

Therefore, by that standard, no entity other than the patient, or their family or friends or social groups, or articles they read, could suggest having such a consultation.

Each person wanting such a consultation would have to come upon even the information about the availability of such a consultation as an Medicare or insurance benefit from independent sources other than their insurer or health care provider.

This would adequately address the fear I believe. To address Palin's fears adequately requires that the option for such a consultation never be mentioned to a patient by their doctor or insurer unless the patient brings up that they want such a consultation.


  1. This controlling fear of death is, I think, an American condition specifically. As a culture, we try to stay young forever, we work hard not to "look old," we don't respect age, and we don't want to discuss death At All. I agree that this attitude is behind the screams about the "death panels."

    I also agree that I personally would prefer to make some preliminary statements about what I do and don't want at end-of-life. In fact, I have made them; Kaiser Permanente strongly recommends that everyone going in for a major surgery file an advance directive, so before my last knee replacement, I filed one. You have no idea how hard it was. It took me most of a week just to get the thing out and look at it. I didn't want to think about it. And I, like you, am pretty autonomous and self-directed; but doing that form scared the shit out of me.

    If I feel this way, how must it be for people who are easily pressured, who are used to "sacrificing" for the family? Will even the loose arrangements you describe make them comfortable with the idea of end-of-life planning, or will they always reject even the idea of it? As always, education is the answer here. I don't know why we never understand that the best way to get people to support your project is to explain how it works and why it will benefit them. The article you posted on the Midwestern hospitals working with this should be mandatory reading.

  2. hedera, good points. It's so interesting that even when you are looking at a paper to sign about possible scenarios, when it comes down to it, it is not at all easy to contemplate possible dying. Who would want to sign a paper that says "ok, go ahead and pull the plug in situations A, B, or C?" unless they have been through a great deal of life or suffering? I think that I would want to have an advance directive only for the most narrow (and not likely) situations at this point in my life, in mid age. I think that when I am 94, I will feel like having more and different details on what I want and don't want, but its fair to say you'd have to be there to really know. It depends on how things are!