The death-panel myth started with a harmless minor provision in the health reform bill that required Medicare to pay in case enrollees wanted to have conversations with their own doctors about "advance directives" like health care proxies and living wills. The controversy that ensued, thanks to a host of right-wing commentators and Sarah Palin's Facebook page, ensured that the advance-planning measure was expunged from the bill. But the underlying debate didn't end with the passage of health care reform, any more than it began there. For if rationing is inevitable once you've ruled out reining in private profits, the question is who should be denied care, and at what point. And given that no one will publicly argue for withholding cancer treatment from a seven-year-old, the answer almost inevitably seems to come down to what we spend on people—old people—in their final years.
As far back as 1983, in a speech to the Health Insurance Association of America, a then-57-year-old Alan Greenspan suggested that we consider "whether it is worth it" to spend so much of Medicare's outlays on people who would die within the year. (Appropriately, Ayn Rand called her acolyte "the undertaker"—though she chose the nickname because of his dark suits and austere demeanor.)
Not everyone puts the issue in such nakedly pecuniary terms, but in an April 2009 interview with the New York Times Magazine, Obama made a similar point in speaking of end-of-life care as a "huge driver of cost." He said, "The chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here."
When geezers are empowered to make choices about our dying days, most of us will choose less aggressive—and less costly— treatments.
The president was being a bit imprecise: Those figures are actually for Medicare expenditures, not the total health care tab, and more important, lumping the dying together with the "chronically ill"—who often will live for years or decades—makes little sense. But there is no denying that end-of-life care is expensive. Hard numbers are not easy to come by, but studies from the 1990s suggest that between a quarter and a third of annual Medicare expenditures go to patients in their last year of life, and 30 to 40 percent of those costs accrue in the final month. What this means is that around one in ten Medicare dollars—some $50 billion a year—are spent on patients with fewer than 30 days to live.
Pronouncements on these data usually come coated with a veneer of compassion and concern: How terrible it is that all those poor dying old folks have to endure aggressive treatments that only delay the inevitable; all we want to do is bring peace and dignity to their final days! But I wonder: If that's really what they're worried about, how come they keep talking about money?
At this point, I ought to make something clear: I am a big fan of what's sometimes called the "right to die" or "death with dignity" movement. I support everything from advance directives to assisted suicide. You could say I believe in one form of health care rationing: the kind you choose for yourself. I can't stand the idea of anyone—whether it's the government or some hospital administrator or doctor or Nurse Jackie—telling me that I must have some treatment I don't want, any more than I want them telling me that I can't have a treatment I do want. My final wish is to be my own one-member death panel.
A physician friend recently told me about a relative of hers, a frail 90-year-old woman suffering from cancer. Her doctors urged her to have surgery, followed by treatment with a recently approved cancer medicine that cost $5,000 a month. As is often the case, my friend said, the doctors told their patient about the benefits of the treatment, but not about all the risks—that she might die during the surgery or not long afterward. They also prescribed a month's supply of the new medication, even though, my friend says, they must have known the woman was unlikely to live that long. She died within a week. "Now," my friend said, "I'm carrying around a $4,000 bottle of pills."
Perhaps reflecting what economists call "supplier-induced demand," costs generally tend to go up when the dying have too little control over their care, rather than too much. When geezers are empowered to make decisions, most of us will choose less aggressive—and less costly—treatments. If we don't do so more often, it's usually because of an overbearing and money-hungry health care system, as well as a culture that disrespects the will of its elders and resists confronting death.
Once, when I was in the hospital for outpatient surgery, I woke up in the recovery area next to a man named George, who was talking loudly to his wife, telling her he wanted to leave. She soothingly reminded him that they had to wait for the doctors to learn the results of the surgery, apparently some sort of exploratory thing. Just then, two doctors appeared. In a stiff, flat voice, one of them told George that he had six months to live. When his wife's shrieking had subsided, I heard George say, "I'm getting the fuck out of this place." The doctors sternly advised him that they had more tests to run and "treatment options" to discuss. "Fuck that," said George, yanking the IV out of his arm and getting to his feet. "If I've got six months to live, do you think I want to spend another minute of it here? I'm going to the Alps to go skiing."
I don't know whether George was true to his word. But not long ago I had a friend, a scientist, who was true to his. Suffering from cancer, he anticipated a time when more chemotherapy or procedures could only prolong a deepening misery, to the point where he could no longer recognize himself. He prepared for that time, hoarding his pain meds, taking care to protect his doctor and pharmacist from any possibility of legal retribution. He saw some friends he wanted to see, and spoke to others. Then he died at a time and place of his choosing, with his family around him. Some would call this euthanasia, others a sacrilege. To me, it seemed like a noble end to a fine life. If freedom of choice is what makes us human, then my friend managed to make his death a final expression of his humanity.
My friend chose to forgo medical treatments that would have added many thousands of dollars to his health care costs—and, since he was on Medicare, to the public expense. If George really did spend his final months in the Alps, instead of undergoing expensive surgeries or sitting around hooked up to machines, he surely saved the health care system a bundle as well. They did it because it was what they wanted, not because it would save money. But there is a growing body of evidence that the former can lead to the latter—without any rationing or coercion.
One model that gets cited a lot these days is La Crosse, Wisconsin, where Gundersen Lutheran hospital launched an initiative to ensure that the town's older residents had advance directives and to make hospice and palliative care widely available. A 2008 study found that 90 percent of those who died in La Crosse under a physician's care did so with advance directives in place. At Gundersen Lutheran, less is spent on patients in their last two years of life than nearly any other place in the US, with per capita Medicare costs 30 percent below the national average. In a similar vein, Oregon in 1995 instituted a two-page form called Physician Orders for Life-Sustaining Treatment; it functions as doctor's orders and is less likely to be misinterpreted or disregarded than a living will. According to the Dartmouth Atlas of Health Care, a 20-year study of the nation's medical costs and resources, people in Oregon are less likely to die in a hospital than people in most other states, and in their last six months, they spend less time in the hospital. They also run up about 50 percent less in medical expenditures.
It's possible that attitudes have begun to change. Three states now allow what advocates like to call "aid-in-dying" (rather than assisted suicide) for the terminally ill. More Americans than ever have living wills and other advance directives, and that can only be a good thing: One recent study showed that more than 70 percent of patients who needed to make end-of-life decisions at some point lost the capacity to make these choices, yet among those who had prepared living wills, nearly all had their instructions carried out.
Here is the ultimate irony of the death-panel meme: In attacking measures designed to promote advance directives, conservatives were attacking what they claim is their core value—the individual right to free choice.