Though I did not realize it on either occasion, I have twice served on death panels. The first was more than two decades ago, when my grandmother was ill and there was little hope of recovery. My grandfather asked me (in passing, to be sure; I was 16) whether we ought to prolong her life by artificial means or let her die what I clearly remember his calling "a noble death." Then, last year at this time, my father was diagnosed with a fatal case of lung cancer (three packs of cigarettes a day for 40 years will do that to you) and quickly ended up on a respirator for several days, with, the doctors advised, no hope of ever waking up. His wife and I consulted over a painful weekend and made what was to us a clear decision. A priest was summoned, prayers said, and the machines turned off. He died within moments.
Such situations are not what the right-wing opponents of President Obama's health-care reform were thinking of when they coined the term "death panels," a lie crafted to foment opposition to the president's push for reform. In fact, the origins of what became the dreaded death panels show the idea to be sensible and humane: the proposal was to encourage families to consult with their doctors about end-of-life care. The phrase is at once politically brilliant and horribly misleading.
The original bill was heading in the right direction: Americans do spend an inordinate amount of money (30 percent of Medicare, for instance) on care in the last six months of life. On the one hand, that makes sense, for if you are dying anything other than a sudden death, you are, by definition, sickest in the last stages. But on the other hand, R. Sean Morrison of the National Palliative Care Research Center estimates that we could save $6 billion a year if we better matched treatments to patient goals and wishes during serious illness and at the end of life.
This post-hope dividend is one potential savings in a system that consumes ever more of our dollars and productivity. Our cover this week is of course hyperbolic, but the issues surrounding end-of-life care are so uncomfortable that if our overstatement can prompt some conversations about this touchiest of subjects, then we will have done our job. As Evan Thomas writes, "The need to spend less money on the elderly at the end of life is the elephant in the room in the health-reform debate. Everyone sees it but no one wants to talk about it."
Who can blame them? The fear of death is one of the most primal and perennial human instincts, if not the most primal. In our own day, the decisions about how far to go to prolong the life of a loved one are among the most wrenching many Americans ever face. Patients vacillate; families disagree; doctors have different opinions.
Progressive reformers are right to fulminate about the dishonesty of the right. But the more liberal voices in the debate cannot only take comfort in their moral superiority or find affirmation in the boorish behavior of obstructionists like the suddenly notable congressman from the Second District of South Carolina. Reformers are obliged to raise the most uncomfortable of questions: how to truly extend coverage to the uninsured without creating insurmountable debt. At least two things are critical to accomplishing this. First, malpractice reform would reduce the pressure on doctors and hospitals to overtreat patients as a matter of defensive medicine. Second, we have to think about death differently—a difficult task, and not a subject likely to be illuminated in short hits on cable television. But without a shift from late-in-life overtreatment to a wider use of the hospice model, costs will continue to grow to a likely unsustainable level.
Collectively, the will of the country, as expressed in the insurance market and in our politics, may be that we want end-of-life care at its current rate or an even higher one. I think such a consensus would be unfortunate. There are ways to shift incentives for doctors that might alleviate some of the pressure they feel to press on with treatment beyond a sensible point; Evan details some of them.
There is, however, no grand edict or policy change that will solve the issue of overly expensive end-of-life care. As with so many other things, the answer will lie with patients (and many conversations about what lengths to go to can be had before a person becomes a patient), their families, doctors, and nurses. The decisions will not be easy. But little is.