Health reform: August 2009 Archives

In recent weeks, we've heard end-of-life counseling compared to government run "death boards."

This rhetoric is beyond irresponsible, but it lays bare a very important problem--too many of us have no idea what living wills and other advance directives do, or how they work.

So, a brief primer: In short, these legal documents allow you to tell doctors and hospitals in advance how you wish to be cared for should you be unable to communicate after suffering an illness or accident. If you are in a coma after a car crash, or are unable to speak or write following a stroke, medical professionals can learn your wishes through your living will. A second document, called a health care proxy or medical power of attorney, designates someone--a spouse, adult child, friend, or lawyer, to act as your advocate to be sure the wishes expressed in your living will are carried out.

It isn't any more complicated than that. But claims that these documents are a way to hasten death are simply wrong. A living will can be used to express any wishes for end-of-life care. If you want no extraordinary measures taken to keep you alive, you may use the living will to say so. But if you want absolutely everything possible done, you may use a living will to request that as well. Had Terri Schiavo made a living will that requested that her feeding tube not be withdrawn, that whole awful legal controversy may have been avoided.

The reality of living wills is far from the alleged euthanasia that critics of health reform are claiming. But deliberately or not, their claims do a terrible disservice to those elders who are thinking about advance directives and those adult children who are caring for their parents.       

The most bizarre episode so far in Washington's health care debate is the persistent rumor that the House version of reform would force Medicare patients to participate in counseling sessions where they would "learn how to end their life sooner."

This is a lie. The House bill would do no such thing. Yet the myth persists, thanks to constant repetition by conservative radio talk show hosts such as Sean Hannity, Rush Limbaugh, and the cast at Fox News. It has successfully distracted attention from bigger issues in health reform. But, most troubling, it has revealed a profound misunderstanding of critical end-of-life matters.

First, though, this is what the bill would do: It merely says that if a patient chooses to consult his doctor about end-of-life issues, Medicare will pay the physician for her time. That's pretty much it. No forced meeting. Nothing about lessons in how to die sooner. Just payment for a once-in-five years discussion about advance directives, living wills, and health care options at the end of life.

Leaving aside for just a moment the rank cynicism in the attacks on this proposal (I'll get back to it though, I promise), think about what its critics are suggesting. They are confusing a foggy notion of libertarian freedom with ignorance. The same people who demand we teach children the fantastical notion that evolution is false imply there is something profoundly wrong with doctors and their adult patients discussing terminal illness and end-of-life. This is not a surprise, of course. The same people have been making the same argument about discussing pregnancy and birth control options for years. When it comes to political correctness, these loonies have left the Modern Language Association in the dust. 

For too long, Americans have had a catastrophic blind spot when it comes to death. We don't want to think about it, talk about it, or plan for it. As a result, too many of us die a death that is needlessly painful and isolated, surrounded by technology and strangers rather than quiet and friends.

The medical ethnologist Frances Norwood spent more than a year studying end-of-life issues in the Netherlands, where euthanasia has been legal for the past quarter-century. There, the kind of candid doctor/patient discussion about end-of-life that so terrifies some American conservatives is quite common. And Norwood reports a remarkable phenomenon: While people talk about euthanasia, they rarely choose it. Indeed, she suggests, the very fact that patients can honestly discuss these tough issues with their families and doctors may actually discourage assisted suicide.

We are not the Dutch, I know, but it is funny how these things work out.        

Now, back to the cynical politics. There is an old story about Lyndon Johnson's first campaign for Congress. LBJ, just learning the ruthless art of Texas politics, was losing badly. To turn the tide, he planned to start a rumor that his opponent, a farmer, was known to have sex with his pigs. A horrified aide tried to warn Johnson that there was no evidence for such a claim. "Well," Johnson was said to reply, "we'll make the SOB deny it."

It is a lesson right-wing radio talkers have learned well.