Moving Away From Death Panels: Health Reform for the Way We Die

There is surprisingly little disagreement about what constitutes good care at the end of life, but we still can't seem to fix any of our problems.

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Later this month the United States Supreme Court will dedicate three days for hearings on the Affordable Care Act (ACA). As the Justices deliberate whether the federal government has the authority to require individuals to purchase health insurance, health care reform is certain to figure prominently in the presidential campaign. Core national values are at stake. With health care costs surpassing 16 percent of our gross domestic product, budget deficits soaring, and nearly 50 million Americans without health insurance, the question is not merely how to pay for health care, but what it means to live in community with one another, rather than merely in proximity to one another.

Debate over the ACA, commonly called ObamaCare, is likely to remain acrimonious. Tempers have flared over payment for abortion services and contraception. At the other end of life, tensions smolder. Social conservatives particularly distrust the motives of health reformers, suspecting that policy makers and bureaucrats give higher priority to cutting costs than respecting and preserving life.

Culture war politics has already derailed a valuable provision in the original version of health reform that would have reimbursed doctors for appointments to discuss patient's preferences for care at the end of life. In the summer of 2009, the bill's opponents tied the clause to everything from "death panels," to killing Granny, to euthanasia. So, despite having had broad bipartisan support when the bill was written, Democrats pulled the plug on that section.

It's time for conservatives and progressives to declare a truce before we lose opportunities for health reform to improve the way Americans are cared for and die.

The opponents' hyperbole was tactical, meant to engender fear and anger among the Republican base of social conservatives. Unfortunately, it became fuel for a theater of cultural conflagration that need not exist.

In fact, there is surprisingly little disagreement about what constitutes good care at the end of life. A year before the kerfuffle, Governor Sarah Palin signed a proclamation encouraging all Alaskans to have discussions with their families about their preferences for care and to complete advance directive documents. Prior to that summer Newt Gingrich spoke often about the exemplary care that his wife's father and their family had received at Gundersen Lutheran Hospital in La Crosse, Wisconsin, as he died in 2006, care which included thorough advance planning conversations.

A February 2011 member survey by the National Association of Evangelicals (NAE) confirmed that evangelicals "honor life from womb to tomb." It also revealed that a large majority accepted death as a part of life. Eighty-five percent of comments on the survey expressed concerns about extraordinary measures to prolong life. This sentiment is consistent with long-standing position statements of the NAE, which state, "We believe there is a profound moral distinction between allowing a person to die, on the one hand, and killing on the other," and "[M]edical treatment that serves only to prolong the dying process has little value."

It's time for conservatives and progressives to declare a truce on these issues before we lose valuable opportunities for health reform to substantially improve the way Americans are cared for and die.

Major improvements are urgently needed and the challenges we face cross cultural and political lines. For one thing, people are a lot sicker before they die than at any time in history. Up until the middle of the 20th century, life-threatening injuries, infections, or heart attacks would swiftly waft people away. The first episode of pulmonary edema commonly killed those with congestive heart failure. Cancer was typically an illness that lasted weeks. Nowadays, people commonly survive even severe trauma, are cured of infections, and live for many months and sometimes years -- often quite well -- with cancer, heart, lung, kidney, and liver disease. In effect, we invented chronic illness. That's a very good thing.

Presented by

Ira Byock

Ira Byock is director of palliative care at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and author of The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.

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