Human Exceptionalism

Advance Planning Yes, Bureaucracy No

I was flattered to be mentioned in the New York Times today by Brendan Nyhan in a piece about paying doctors to engage in end-of-life conversations with patients, and how these talks are not “death panels.” From, “Can We Have a Fact-Based Conversation About End-of-Life Planning:”

Support for covering voluntary end-of-life planning is actually remarkably strong across the political spectrum. In addition to the American Medical Association panel’s recommendation, both private insurers and states such as Colorado and Oregon are now offering coverage for these consultations.

Even critics of President Obama’s health care plan such as National Review’s Wesley J. Smith and Senator Johnny Isakson, Republican of Georgia, are in favor of advance planning.

I am not sure why the word “even” is in there. Surely one can adamantly oppose Obamacare–as I do, primarily because it opened the door to centralized bureaucratic control–and believe that doctors should discuss these matters with patients: Walking and chewing gum at the same time.

But to say that one is “for conversations” isn’t enough. The circumstances in which the talks occur matter too. So, to be clear, these are my positions:

– Doctors should discuss these matters whether they are paid or not. It is part of the job of physician.

– The conversations should be an ongoing dialogue, not a one off.  Some worry that paying for the talks will dictate when the discussions occur. I don’t think the talks pay enough for that, but it is a reasonable concern.

The talks should not be designed to convince people to refuse treatment based on costs. The doctor should not represent “society” in these discussions. That would be a conflict of interest.

We should not bureaucratize these conversations ancillary to paying for them. Thus, I wrote against a Senate bill that would have dictated the hoops through which doctors and patients had to jump to make the conversations compensable–and even established a federal advisory board, appointed by the president and the leaders of Congress. Good grief.

– These discussions should be with doctors if they are to be paid by insurance or government, and not with special interest groups. In this regard, I have warned that the assisted suicide advocacy organization Compassion and Choices–which bragged about being behind the failed Obamacare proposal to pay doctors or specialist organizations–wants to become the Planned Parenthood of death. That can’t be allowed.

– Talk isn’t enough. Everyone should sign an advance directive appointing a surrogate in the event of incapacity. Stating that you don’t want to be pushed out of the lifeboat makes it harder to push you out of the lifeboat.

– Rather than pay doctors to have these discussions, better to raise physician compensation generally with the understanding that the “talks” are expected as part of the compensation package. Think of the saved paperwork!

End-of-life conversations are controversial because people know that technocratic types hope to cut costs by restricting access to care to the most expensive patients, particularly those deemed to have a low quality of life–which is why the “death panel” warning resonated so deeply.

But silence is the wrong strategy. Discussing these issues openly make a death panel outcome more difficult to impose.


The Latest