President Obama and Death Panels
Posted on August 21, 2009
Filed Under Healthcare Reform |
When Sarah Palin uttered the fateful words, “Death Panels,” she unleashed the holy wrath of the great unwashed masses, and as a result caused many of our more complacent legislators to abruptly bestir themselves into a higher state of arousal, if not outright agitation. Palin’s accusation caught more than a few of them utterly unawares, and embarassingly flatfooted.
They felt, no doubt, like they were in that dream where you unaccountably find yourself naked in a crowd. But this time, rather than reaching to hide their sadly exposed nether parts, they reached instead for their pristine copies of HR 3200. One could almost pity them, desperately rifling through the 1100 virgin pages, wondering whether perhaps they should have tried to read that monstrosity earlier after all, and muttering to themselves, “Death panels? This damned thing has death panels?”
But DrRich is here to reassure them. First, as he has recently pointed out, there was in fact no reason for them to waste their time trying to read HR 3200. It was not designed for reading, comprehensibility, or (for that matter) imparting any actual information of any sort.
And second, HR 3200 contains no death panels. (In their state of stark panic, of course, and anxious to rid the bill of anything that might smack of death panels, our legislators quickly moved to strike Section 1233 from the bill, apparently because that section contains the phrase “end-of-life care.” But actually, Section 1233 talks about end-of-life counseling, and not death panels. Nothing in HR 3200 creates death panels.)*
The very notion of death panels seems to have many supporters of healthcare reform nonplussed. How can someone as inarticulate and obviously illiterate as Sarah Palin get away with accusing our highly-educated healthcare reformers of setting up such a thing as death panels? Really, what are death panels anyway? And even more perplexingly (since, after all, Republicans are capable of anything), why do so many Americans believe her - even, apparently, hundreds of thousands of Americans who were enlightened enough to vote less than a year ago for President Obama?
This question ought to greatly concern any of our elected representatives who support healthcare reform and who plan on being returned to Congress.
When Sarah Palin said, “Death Panels,” she was dropping one last, tiny crystal into a supersaturated solution. Her words took what had been an amorphous and even chaotic sense of unease about healthcare reform, and immediately crystallized it into an organized latticework of directed rage and fear. So the real question (for politicians hoping to seek re-election) is not how Sarah Palin came to be savvy enough to know just the right words. (Perhaps she was just “lucky,” or perhaps - and DrRich suspects this is the real explanation - she is a lot smarter than her critics allow.) Rather, the real question is: What put the rabble in such a supersaturated state to begin with? Why did the absurd-on-its-face idea of “death panels” so resonate with them? What made those words galvanize their shapeless disquiet into a solid mass of resistance?
DrRich is very sorry to have to tell his friends of the Democratic persuasion the sad truth - it was President Obama who created this circumstance. Sarah Palin may have named the death panels, but before she ever thought of the phrase, President Obama had already described them in some detail.
He described their function, how they would operate, and who they would target. During the past 6 months President Obama has actually offered several short discussions on what a “death panel” might be expected to accomplish. But perhaps the most instructive example is the one he gave on ABC television during his June 24 National Town Hall meeting.
DrRich refers, of course, to the famous question about the 100-year-old woman who received a pacemaker. The questioner pointed out that her grandmother had badly needed a pacemaker, but had been turned down by a doctor because of her age. A second doctor, noting the patient’s alertness, zest for life, and generally youthful “spirit,” inserted the pacemaker despite her advanced age. Her symptoms resolved, and Grandma continues to do well 5 years later. The question for the President was: Under an Obama healthcare system, will an elderly person’s general state of health, and her “spirit,” be taken into account when making medical decisions - or will these decisions be made according to age only?
President Obama’s answer was clear. It is really not feasible, he indicated, to take “spirit” into account. We are going to make medical decisions based on objective evidence, and not subjective impressions. If the evidence shows that some form of treatment “is not necessarily going to improve care, then at least we can let the doctors know that - you know what? - maybe this isn’t going to help; maybe you’re better off not having the surgery, but taking the pain pill.”
(DrRich will give President Obama the benefit of the doubt regarding his suggestion that a 100-year-old women who needs a pacemaker might be better off with a pain pill. Despite the way he is portrayed on the cover of Time Magazine, Mr. Obama is not actually a doctor, and cannot be expected to understand that using a “pain pill” to treat an elderly woman who is lightheaded, dizzy, weak and possibly syncopal because of a slow heart rate might justifiably be considered a form of euthanasia rather than comfort care. DrRich does not believe the President was intentionally suggesting the old woman’s death should be actively hastened by means of a pain pill. At the same time, DrRich’s advice to this still-spry 105-year-old Grandma is: since pacemakers usually need to be replaced every 6 - 7 years, you’d better think about having your 5-year-old pacemaker replaced right now, before the Obama plan has a chance to become law.)
President Obama’s answer in this case tells us several things. 1) There will be a panel, or commission, or body of some sort, that is going to examine the medical evidence on how effective a certain treatment is likely to be in a certain population of patients. 2) This (let’s call it a “panel”) panel will “let the doctors know” whether that treatment ought to be used in those patients. (”Letting the doctor know” is a euphemism for “guidelines,” which itself is a euphemism for legally-binding and ruthlessly enforced directives.). 3) “Subjective” measures (such as a physician’s clinical judgment as to an individual’s likelihood of responding to a therapy as the panel says they will - or, for that matter, a person’s “spirit”) ought not to influence these treatment recommendations, since that kind of subjective judgment is what got us into all this fiscal trouble in the first place. 4) But being that our government is a compassionate and caring one, palliative care will be made available in the form of pain control, even while withholding potentially curative care.
So, according to the President, we will have an omnipotent “panel,” acting at a distance and without any specific knowledge of particular cases, that will tell a doctor whether he/she can offer a particular therapy to a particular patient - or whether, instead, to offer a “pain pill.” His description of this process, offered with variations over the past several months in several venues, has obviously made quite an impression among the people. Of course, Mr. Obama is widely known to be a gifted communicator.
In any case, all that remained was for Sarah Palin to give the President’s panel a catchy name. And when she did, the American people (without reading HR 3200 or any other piece of legislation) knew exactly what she was talking about. They knew, because President Obama himself had been spelling it all out for them in plenty of detail for six months.
Indeed, it seems to DrRich that, if not for Mr. Obama’s having so carefully laid the groundwork, Palin’s accusations of “death panels” would have fallen flat. It would have been regarded by most people as the absurdity Democrats insist that it is, rather than the epiphany it turned out to be.
* There are no death panels in HR 3200 because creating them there would have been entirely superfluous. If we are to have death panels, or any entity that might pass as one, the provision for such a panel is already the law of the land. It was made so earlier this year (conveniently, before anybody started paying attention) in the Stimulus Bill, which created the Federal Coordinating Council for Comparative Effectiveness Research.
DrRich has described before how the CER Council will perform cost-effectiveness calculations, then coerce physicians, through one form of federal subterfuge and intimidation or another, to employ the least expensive therapies (thus enforcing “cost”, while shouting “effectiveness”).
It is called a CER Council, and not a death panel. But if you should develop a fatal illness which you might have survived had you been allowed to receive a treatment that the Council has deemed cost-ineffective, then you might be forgiven for thinking of the CER Council (from your insular, personal, narrow-minded, self-interested point of view), as a death panel. But there are no death panels in HR 3200, and Sarah Palin should be ashamed of herself for suggesting otherwise.
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16 Responses to “President Obama and Death Panels”
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Dr. Rich, great post as always! I am not sure that I agree with you (also as always :)). Do you really think that a spy and viable 100-year-old will not get a PM ever in the US? I think that there are enough people withe common sense (including you, Dr. Rich) who can educate our government bureaucrats of the real definition of EBM, which conspicuously incorporates judgment.
I also have to disagree that we were primed for this furor by Obama. If Dr. Rich looks at the history of our hc reform efforts, same tactics were used in the ’50s and the ’90s by the opposition. This time around there was a need for something slightly more drastic than the threat of communism or fascism, since there is a widespread perception that we need reform. so instead of cold war rhetoric we went to death panels.
I have blogged about this in several of my posts, but the one particularly relevant is “Death and taxes” which can be found here:
http://evimedgroup.blogspot.com/2009/08/death-and-taxes.html
As always, great to have civilized dissent!
Forgot to mention that I love your posts so much that I have now put a link to your blog from mine!
I have a suggestion for whom should be the first (ex-governor)to go before these death panels…
The Federal Coordinating Council for Comparative Effectiveness Research (let’s call it FECCCER) looks to be analogous to the British National Institute of Clinical Excellence (NICE).
I have a feeling that my 91-year old father needing intubation for pneumonia would not have fared very well with either. He also would up getting the short end of the stick in 2003 under the current Utopian system as well.
He was forcibly euthanized.
http://www.aneustadter.com/cover_1-3-06.pdf
The regulatory agencies turn a blind eye.
http://www.aneustadter.com/ohcq_1-8-09.pdf
Regrettably, I can vouch for Dr. Rich’s observations about the multiple loyalties of our doctors, and about the lack of honesty and covert rationing that is with us in a big way today. Perhaps FECCCER would at least bring transparency to the rationing, and allow patients to try to take evasive action if so inclined.
“But there are no death panels in HR 3200, and Sarah Palin should be ashamed of herself for suggesting otherwise.”
That’s all you had to write. Jeez.
Marya,
Your death and taxes post makes a very good point. However, I think both sides are guilty of grossly oversimplifying the issue, and guilty of misleading.
My policy has been to focus my sarcasm and disparagement on whichever side I see as being on top at the moment. My book, my previous website (now defunct) and early posts on this website hit the insurance industry pretty hard. My focus on the Democrats of late should be seen as a compliment to them. They are winning.
But if either side gets their way, and proceeds to continue rationing covertly, whether by the dastardly deeds of the insurance industry or the heavy hand of the feds, we all lose.
But until one side or the other begins to talk openly about the need for rationing, and discussing a transparent way of doing it, I say a pox on both their houses.
Rich
joegrind,
Be nice. There are plenty of suitable ex-governors to go around.
Rich
Al,
FECCCER! My gosh! It’s too beautiful. Do you suppose that was intentional? Do you think Rahm said, “We need an acronym that is at least as evocative as NICE, but perhaps without that Orwellian irony. One that tells it like it is. How about FECCER?”
I agree with you, by the way, that a general public awareness of the potential power and potential aribitrariness of FECCER, and a public reaction to it, might be the most straightforward path to a system of open rationing.
Rich
Reality,
Perhaps, but in case you haven’t noticed, I am utterly incapable of that degree of pith.
Rich
An example about unease about healthcare reform was prompted by a recent New York Times front page article (1) where the author suggests that for prostate cancer watchful waiting is attractive and inexpensive and implies that healthcare reform will be meaningful only when more expensive treatments are abandoned.
No one can argue with using objective, scientific evidence as opposed to biased sources. Unfortunately, it’s not that easy to come by as shown by another New Your Times article (2) where a 2006 diabetes treatment guideline was withdrawn.
1. http://www.nytimes.com/2009/07/08/business/economy/08leonhardt.html?_r=1
2. http://www.nytimes.com/2009/08/18/health/policy/18diabetes.html?_r=1&partner=rss&emc=rss&pagewanted=all
…will an elderly person’s general state of health, and her “spirit,” be taken into account when making medical decisions - or will these decisions be made according to age only?
I think medical decisions at ALL ages should take general health and “spirit” into account. Deny joint replacement surgery and dialysis for 67-year-old non-compliant smoking diabetic vasculopaths and there will be plenty of money for pacemakers for vigorous 100-year-olds.
“President Obama’s answer was clear. It is really not feasible, he indicated, to take “spirit” into account.
He’s talking about rules. You can’t make a rule about spirit one way or the other.
Obama: “I don’t want bureaucracies making those decisions.”
You’re being so disingenuous it’s close to simply lying.
http://abcnews.go.com/Politics/HealthCare/Story?id=7920012&page=2
—-
My question to you is, outside the medical criteria for prolonging life for somebody elderly, is there any consideration that can be given for a certain spirit, a certain joy of living, quality of life? Or is it just a medical cutoff at a certain age?
OBAMA: Well, first of all, I want to meet your mom.
(LAUGHTER)
OBAMA: And I want to find out what’s she’s eating.
(LAUGHTER)
OBAMA: But, look, the first thing for all of us to understand is
that we actually have some — some choices to make about how we want to deal with our own end-of-life care. And that’s one of the things I think that we can all promote, and
this is not a big government program. This is something that each of us individually can do, is to draft and sign a living will so that we’re very clear with our doctors about how we want to approach the end of life. I don’t think that we can make judgments based on peoples’ spirit. That would be a pretty subjective decision to be making. I think we have to have rules that say that we are going to provide good, quality care for all people.
…We’re not going to solve every single one of these very difficult
decisions at end of life, and ultimately that’s going to be between physicians and patients. But we can make real progress on this front if we work a little bit harder.
SAWYER: Is that a conversation you could have had with your mom?
STURM: What I wanted to say was, that the arrhythmia specialist who put the pacemaker in said that it cost Medicare $30,000 at the time. She had been in the hospital two or three times a month before that, so let’s say 20, 30 times being in the hospital, maybe going to rehab, the cost was so much more. And that’s what would have happened had she not had the pacemaker.
OBAMA: Well, and that’s a good example of where — if we’ve got experts who are looking at this, and they are advising doctors across the board that the pacemaker may ultimately save money, then we potentially could have done that faster.
I mean, this can cut both ways. The point is, we want to use
science, we want doctors and — and medical experts to be making decisions that all too often right now are driven by skewed policies, by out-dated means of reimbursement, or by insurance companies.
—–
Read the whole transcript.
I agree with you, by the way, that a general public awareness of the potential power and potential aribitrariness of FECCER, and a public reaction to it, might be the most straightforward path to a system of open rationing.
True, but my point is that even FECCCER might be more transparent and honest than the covert rationing we’ve got today. Better a patent be leveled with and told that based on a standard formula, Washington will simply not pay for his intubation or ICU care, than to be less-than-open and to make decisions on the patient’s behalf with the interests of other parties in mind.
“FECCER” is a whole lot less creepy and a lot more forthcoming than “NICE”.
“FECCER” is a whole lot less creepy and a lot more forthcoming than “NICE”.
Less creepy? Not so sure. From the perspective of an elderly or debilitated human being, “Comparative Effectiveness” goes a lot more to the creepy heart-of-the-matter than “Clinical Excellence.” More forthcoming? Maybe. And if so, that’s a good thing because it would at least allow the person on the short end of the stick to know where he stands and try to do something about it if he can.
The Urban Dictionary definition of Feck:
1. It was originally a slang term used in Ireland to mean either a) “to steal” or b) “to throw”.
2. It’s also used as a pretty mild swear word in Ireland.
It’s used a) to express that you’re pissed off or b) to describe somebody who pissed you off.
It’s not related to the word ‘F___’, and doesn’t have any sexual undertones, so is acceptable for polite company.
Once Obamacare becomes a reality, to “Feccer” you (hard ‘C’, pronounced “fecker”) might mean to deprive you of the rightful care you so zealously paid into the system for, or “throw you” off the lifeboat. When you find out your life-saving treatment has been denied because your life is not cost-effective, you would say, “I’ve been Fecced.”
Love your comments, & love your book.
I’ve got the non-envious job of working within an “explicit” rationing environment in New Zealand, working with clinicians, surgeons and the disability sector developing prioritisation criteria to determine the rank order priority of people for access to publicly funded elective healthcare services. Really interesting reading comments regarding pacemaker services for the elderly and the benefits of ICDs - I have also come from a cardiological background (imaging & electrophysiology) in the days before HIV when we recycled pacemakers for the benefit of many without the rates of infection everyone supposes might occur. What a shame we can’t do that anymore. Would love to talk more with you about your fix-it theories and ours particularly your EOS concepts in the context of duration of benefit (we have duration, magnitude (an attempt at the degree to which an intervention will reverse the impact on life (IOL) measured on the same scale, and likelihood of achieving that magnitude and duration if deterioration is predicted.) We have a novel methodology of weighting these values using conjoined analysis. The argument regarding age is interesting, its often a surrogate for other issues, and the relationship with duration of benefit is not always linear - so ’spirit’ is an interesting concept.
Perhaps we could converse more?
Regards
Ali