This is Chapter 13 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.
You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.
And here is the up-to-date archive for all the chapters that have been posted so far.
Update – September 1, 2012
Open Wide and Say Moo! is now revised and published!
Now available in the audiobook version!
In the last chapter, without calling it out, we introduced a new concept of Progressive healthcare – Group Medicine.
Group medicine is a subcategory of herd medicine. Under group medicine, a group of individuals sharing some common characteristic – such as obesity – is culled out from the greater herd for “special treatment.” The people included in that group will still not receive individualized healthcare; they will still be treated under the one-size-fits-all principles of herd medicine. It’s just that the rules guiding their medical care will be specific for their group.
In this chapter we will address the biggest group of all – old people – and the special problem the individuals included in this group present to a Progressive healthcare system, namely, what to do about end-of-life-care.
It is unfortunate that one cannot engage in a dispassionate and objective analysis of the Progressives’ ideas on age-based medicine and end-of-life healthcare without being immediately accused of invoking “death panels,” and thus of displaying the dearth of sophistication, the lack of understanding, and the primitive logic commonly attributed by Progressives to Sarah Palin.
I must remind my readers that I have yet to use the term “death panel” to refer to any of the multitude of expert commissions created by Obamacare, whose charge will be to dispassionately examine the scientific evidence in order to determine which patients will get what, when and how. These bodies, in fact, will be explicitly aiming to optimize the medical outcomes of the entire population (titrated to the amount of money we’re allowed to spend on healthcare), and not actively prescribing death for anyone.
Judging from the histories of governments which have adopted a collectivist philosophy, if death panels should appear on the scene they will not be aimed at determining which patients may live or die. That job, of course, will fall to the doctors at the bedside, who will offer or withhold medical services according to the dictates (i.e., “guidelines”) handed down by those sundry expert commissions. Rather, any death panels which might eventually materialize will more likely be aimed at keeping those doctors themselves (and any other functionaries whose job is to do the bidding of the Central Authority) in thrall.
So why has the term “death panel” caught on to such an extent that conservatives so often use it as shorthand to express what they see as the “sense” of Obamacare, and Progressives so often use it to accuse rational and mild-mannered critics of Obamacare (such as your humble author) of belonging to the Neanderthal persuasion?
While most would blame Sarah Palin for coming up with this unhelpful phraseology, it is my view that President Obama himself must carry at least an equal part of the blame. For, if Progressives have not created actual death panels, they at least created the environment in which those words, when Ms. Palin first uttered them, immediately caught fire.
One should recall that when, in late 2009, Ms. Palin used the fateful words, “death panels,” the Obamacare legislation was being slowly and painfully shoved through a surprisingly reluctant Democrat Congress. And as a result she 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 embarrassingly 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 the monstrous Obamacare legislation which had been laid before them, and which they famously (and understandably) never read. One could almost pity them, desperately rifling through the 2700 virgin pages, muttering to themselves, “Death panels? This damned thing has death panels?”
But in fact, their initial instincts were correct, at least as regarded the advisability of actually reading the legislation. There was in truth no reason for them to waste their time. I myself have subsequently read large swatches of the thing, and I can assure one and all that it was not designed for reading, comprehensibility, or (for that matter) imparting any actual information of any sort. And besides, Obamacare contained no provisions for creating anything called death panels, so had they read the bill they would not have discovered any.
The very notion of death panels seemed to have many supporters of Obamacare nonplussed. How could 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? And even more perplexingly, why did so many Americans believe her – even, apparently, millions of Americans who had been enlightened enough to vote for President Obama less than a year earlier?
I believe it is this: 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 is not how Sarah Palin came to be savvy enough to know just the right words. (Progressives know that even a distinguished panel of monkeys, given enough time and enough typewriters, will eventually produce King Lear.) 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?
I am very sorry to have to tell my friends of the Progressive persuasion the sad truth. For it was President Obama himself who created this circumstance. Sarah Palin may have first named the death panels, but before she ever thought of the phrase the President had already described them in detail.
During his first year in office, President Obama offered several homilies relating just what a “death panel” would look like. He described their function, how they would operate, and who they would target. Perhaps the most instructive example is the one he gave on ABC television during his June 24, 2009 National Town Hall meeting.
I refer, of course, to the famous question put to him by the granddaughter of a 100-year-old woman who had received a pacemaker. The questioner pointed out that her grandmother had badly needed this 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,” went ahead and inserted the pacemaker despite her advanced age. Her symptoms resolved, and Grandma was still doing quite well five years later. The question for the President was: Under Obamacare, 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.”
I will give President Obama the benefit of the doubt regarding his suggestion that a 100-year-old woman who needs a pacemaker might be better off with a pain pill. 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. I do not believe the President was intentionally suggesting the old woman’s death should be actively hastened by means of a pain pill. Indeed, given that repeated falls from lightheadedness would likely have led to a hip fracture had the pacemaker been withheld, a pain pill might eventually have been just the thing for granny.
Still, President Obama’s clear and unflinching answer in this case told us several important things about Obamacare: 1) Under Obamacare, there would be at least one 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 subset of patients. 2) This, let’s call it a “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, as we have seen, is a euphemism for legally-binding and ruthlessly enforced directives.) 3) “Subjective” measures ought not to influence these treatment recommendations. Non-objective parameters – such as the doctor’s medical experience, intuition, or personal knowledge of the patient; or the patient’s “spirit,” or will to live, or likelihood of tolerating and complying with the proposed treatment; or even extenuating circumstances that might increase or decrease the success of the proposed treatment in a particular individual – simply cannot be evaluated or controlled by far-away expert panels, and therefore must necessarily be discounted. 4) But since our government is a compassionate and caring one, and wishes to reduce unnecessary suffering, palliative care will be made available in the form of pain control, even while withholding potentially curative care.
What the American public accurately heard the President say was that 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, repeated with variations over the next several months in several venues, obviously made quite an impact on 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 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 me that, if not for President 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 that Progressives insist that it is, rather than the epiphany it turned out to be.
Progressives who strenuously object to its usage in reference to the expert commissions created by Obamcare can blame Sarah if they want to – but by all rights they should actually be taking up the matter with their dear leader, who is the chief source of the misapprehension, if misapprehension there be.
Whatever you choose to call these expert panels, however, one thing that was very clearly articulated by President Obama is that the directives that are going to be passed down to physicians by these panels, “letting them know” which services they should offer and which they should withhold from which patients, will take the age of the patient into very strong account.
That groups of Americans under Obamacare will be culled out from the herd, to receive medical care according to their age, is all but explicit.
In Chapter 11 we saw a particularly well-known example when we examined the recommendations made by the USPSTF regarding mammogram screening. While the ratio of true-positive versus false-positive mammograms is a continuous variable, which gradually increases with age as you begin testing women as young as in their 20s, and while there apparently is no natural age-related threshold or break point where the test suddenly becomes more (or less) accurate, the USPSTF was pleased to offer an arbitrary age-related cutoff (age 50), above which mammograms are to be offered, and below which they are not.
Whether or not you agree with the new USPSTF guidelines, you must concede the entirely arbitrary nature of the age cutoff. The difference in the risk/benefit ratio of doing mammography in a 49-year-old woman vs. a 50-year-old woman, for instance, is immeasurably small. Yet the cutoff is set – arbitrarily – at 50. This arbitrariness is an essential feature of age-based medicine.
“Well, you’ve got to set a cutoff somewhere,” proponents of Progressive medicine will say. And yes, that is true. And if we were merely talking about general guidelines, and not firm rules which must be obeyed in each case, then the “arbitrariness” of age-based cutoffs would not be a big problem. But if instead you’re going to practice herd medicine, where everyone is treated exactly the same regardless of personal preferences, and you’re going to systematically ignore or disallow the consideration of circumstances that might affect an individual’s response to the proposed medical service, then arbitrary cutoffs are indeed a problem. And from the aspect of the patient (those for whom the health care system, ostensibly, exists in the first place), the arbitrary nature of age-based medicine has a great potential to produce harm.
It is therefore important to note that from the aspect of the Central Authority, age-based medicine is not arbitrary at all. It is entirely objective, and is based on clearly-defined principles.
The Central Authority’s rationale for age-based medicine was perhaps best described by Ezekiel Emanuel, MD, President Obama’s Special Advisor for Health Policy (and brother of Rahm), in an article appearing in The Lancet in January, 2009. entitled, “Principles for allocation of scarce medical interventions.” In this article, Emanuel proposes an ethical basis for rationing healthcare resources based upon age. He calls it the “complete lives system.”
At first blush, if you look at it in a certain way, the complete lives system seems ethically justifiable. In determining who gets what healthcare services it is OK to discriminate against the elderly, Emanuel holds, but not just because they are old and therefore relatively decrepit. Rather, such discrimination is justifiable because every person, over the course of their complete lives, will experience the entire range of healthcare priorities – the high priority of the young, and then, if they are lucky enough to live a long time, the low priority of the old. Thus, all people are treated exactly the same over the course of their lives.
If Emanuel had stopped there, I for one might have grumbled a bit (being an Old Fart myself and thus already dwelling within the low priority stage of my life), but I would have had to admit that, from a certain aspect, the system seems equitable.
But Emanuel did not stop there. Instead, Emanuel went on to elaborate that under his system, it is also perfectly justifiable to discriminate against the very young. Specifically, he says:
“Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritizing adolescents and young adults over infants. Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, in contrast, have not yet received these investments.”
So, Emanuel holds that it is OK to discriminate against infants, toddlers and young children on the grounds that society has not “invested” a lot of resources in them yet. That is, their worth to society is not very great, and their loss would not be noticed very much by the collective.
This provision against the very young fatally undermines the notion that all human lives are of equal intrinsic value (which, Emanuel says, is the premise of the complete lives system), in favor of the idea that an individual’s real worth ought to be determined by their practical value to the state. And so, the state has the right – and the duty – to determine which lives are valuable enough to save, and which are not.
As if to emphasize the objective and scientific nature of his proposal, Emanuel included in his article a graph depicting one’s worth to the state as a function of age. The graph plainly shows that one’s value to the Central Authority begins, at birth, at a very low level. It then rapidly increases to a peak at around age 20. From there it drops gradually until about age 50 – where it plummets to much lower levels by age 60. One’s intrinsic worth to the collective then continues to drop even lower until, at age 75, it returns to the ultra-low levels not seen since birth. The graph precipitously ends, somewhat disturbingly to an Old Fart such as myself, at age 75. (I will have more to say on the magic age of 75 shortly.)
Emanuel’s Lancet article may be the most explicit statement yet provided by an official of the Obama administration on the ethical precepts underlying Obamacare. It places the Central Authority in the position of assigning intrinsic values to groups of human lives, based on how useful those lives are to the aims of the collective (or, how much society has “invested” in a certain class of individuals), so that healthcare priorities can be distributed accordingly.
If you are a patient, age-based healthcare rationing seems arbitrary. But from the point of view of Progressives it is not arbitrary at all; rather, is based on an entirely objective measure. Groups of people who are useful to the aims of the collective are to receive a high priority when it comes to healthcare. Groups of people who are deemed to be not so useful will receive a much lower priority.
Obviously, the criteria for producing such groups does not necessarily have to be limited to age. In fact, when the chief concern is to protect the interests of the collective, it would be wrong to limit your considerations in this way. Other obvious criteria that ought to be considered in devising various groups for the purpose of determining healthcare priorities would reasonably include your tax-generating potential, your IQ, your disabilities, your likelihood of supporting a Progressive agenda, your BMI, and your genetic makeup.
Explicit groupings based on these other parameters are merely conjecture at this point. Age-based groupings are not. Not only has a rationale for age-based healthcare been published in the peer-reviewed medical literature, but also, steps are being taken to put it into effect.
Under Emanuel’s scheme, infants and toddlers have very low value to the collective because very few resources have yet been “invested” in them. For this reason, whether they live or die is of little import to the Central Authority, and so their priority for receiving healthcare services ought to be accordingly low.
So far, thankfully, we see very little evidence in our healthcare system that the very young – once they are born, at least – are being discriminated against. Neonatal intensive care units, for instance, are running full bore, and the people who work in them remain extraordinarily dedicated to doing everything possible to help their tiny charges to survive.
Still, the justification for withholding care from the very young, when the time comes, has been established. And while it is difficult to find evidence of the devaluation of young children within our healthcare system, it is not particularly difficult to find it elsewhere.
Perhaps the most striking example was provided by an article written by two medical ethicists, appearing in early 2012 in the Journal of Medical Ethics, entitled, “After-birth abortion: why should the baby live?” Here is the authors’ abstract:
“Abortion is largely accepted even for reasons that do not have anything to do with the fetus’ health. By showing that (1) both fetuses and newborns do not have the same moral status as actual persons, (2) the fact that both are potential persons is morally irrelevant and (3) adoption is not always in the best interest of actual people, the authors argue that what we call ‘after-birth abortion’ (killing a newborn) should be permissible in all the cases where abortion is, including cases where the newborn is not disabled.”
These medical ethicists, in other words, propose to allow parents to kill their young children for any reason they might have invoked to abort that child prior to birth – that is, for any reason at all. The key point being made by these ethicists is fundamentally the same as the point made by Emanuel’s article. When they are very young, people have no intrinsic value that really matters to society (they are merely “potential persons”), so what happens to them is of no particular concern.
Within the tyranny of experts which we are establishing to run our Progressive society, the medical ethicists are probably the most dangerous of all.
From the very beginning, as I have pointed out, devaluing human lives that are inconvenient to the aims of the collective has been an intrinsic characteristic of Progressivism. Indeed, the reason I am against elective abortion has little to do with religion. It is, in fact, the very same reason why hard-nosed Progressives are so passionately in favor of abortion. It is that making abortion legal requires experts to define some point, after the fertilization of the egg, that precisely defines “human life.”
Such a definition will necessarily be arbitrary, and being arbitrary, will change over time depending on current exigencies. The definition of “human life” has already devolved, over just a few decades, to permit the late-term abortion of babies capable of surviving out of the womb. And now, respected medical ethicists suggest, “human life” does not even include infants, or perhaps even toddlers. Other potential candidates for exclusion from “human life” abound. And today, facing fiscal disaster, the impetus for excluding even more groups from that definition is plainly growing strong.
Even William Saletin, a vocal pro-choice writer for Slate, was troubled by the “after-birth abortion” article. He wrote, “The case for after-birth abortion draws a logical path from common pro-choice assumptions to infanticide. It challenges us, implicitly and explicitly, to explain why, if abortion is permissible, infanticide isn’t.” His ensuing discussion shows clearly, to his own apparent dismay, that there is, in fact, no logical stopping point once “common pro-choice assumptions” are accepted.
People are not yet killing their inconvenient babies, at least not with the full approbation of the authorities. But the ethical groundwork for allowing such actions has been laid, and we in the herd are being desensitized to the idea.
President Obama, in his June, 2009 National Town Hall Meeting, clearly stated that once a person reaches a certain age, that person should not expect even routine healthcare services, such as a pacemaker. He did not identify the threshold age at which he would favor withholding medical services, but indicated that, in any case, that threshold has certainly been crossed by the time one reaches age 100. He wisely avoided indicating that the actual age threshold is substantially lower than that.
But at the time of his Town Hall Meeting, his Special Advisor for Health Policy had already published his article in Lancet detailing the administration’s age-related priorities for healthcare services for anyone who cared to look at them. To review: once you survive to age 20 your priority for healthcare services is and remains high until around age 50, at which time it drops rapidly to age 60, then drops more gradually to extremely low levels by age 75. After age 75 you drop off the map altogether.
Aside from this graphic evidence supplied in Emanuel’s article, there are other indications which strongly suggest that age 75 is to become the magic threshold, above which we ought to stop expecting at least the more expensive varieties of medical care.
The clearest indications come from our friends on the USPSTF, the panel which under Obamacare has the final authority to determine who will and who will not receive preventive healthcare services.
In Chapter 11, we saw that the USPSTF does not want women over the age of 75 to receive any more screening mammograms – despite the fact that breast cancer is a chief killer of women in this age group. For our present purposes the relevant aspect of this recommendation is not the recommendation itself, but the rationale the USPSTF used to arrive at it. That rationale was: a) there are no well-controlled, randomized clinical trials proving that the overall mortality rate of women over 75 is improved with screening mammograms, and b) if such studies ever were to be done, they would likely show no overall benefit anyway, since people in this age group tend to die pretty soon, of something or other.
This should prove to be a very convenient rationale for the Central Authority, since it can be applied to old people for any medical service one can think of. “We are scientists,” the expert panels solemnly pronounce, “and we can go only where the science takes us. Because randomized trials have not been conducted that show a survival benefit with Medical Service X in people over 75, our hands are tied.”
No broad-based randomized clinical trial, measuring any medical intervention whatever, would ever be likely to show an overall survival benefit in a broad population of old people – and this explains why such trials are not done. Fundamentally this means that under the expert panel paradigm favored by any Progressive healthcare system, it will always be easy to render it inappropriate (and illegal) to provide those “unproven” services to the elderly.
Placing the cutoff at 75 years of age is entirely arbitrary. It could just as easily have been 70, or 80, or some other value. But this is the age which the Central Authority pretty clearly has identified as the threshold for which “routine” medical interventions ought to be withheld. Not only is it consistent with Emanuel’s article, but it is also an age that appears in several recent USPSTF directives. Prior to the USPSTF’s recent revision of guidelines for screening for prostate cancer (in which nobody is to have have screening any more), PSA screening was to end at age 75, despite the high incidence of fatal prostate cancer in elderly men. Current recommendations for colonoscopy also stops at age 75, despite the continued risk of colon cancer in the elderly.
From available evidence, therefore, it appears likely that the Central Authority has identified age 75 as the time when people ought to stop expecting routine healthcare services, because, apparently, once you reach age 75 your only remaining duty as a citizen is to die.
In any case, it seems apparent that when you turn 75, the Central Authority assigns you to that group of American citizens (possibly along with infants and toddlers) for which it is inappropriate to spend very much money. If I am correct, then we Old Farts should be alert to the sundry mechanisms which the Central Authority is likely to employ in the attempt to withhold our healthcare.
It is a famous axiom of those who decry the waste that takes place within the healthcare system, and who argue for tighter control over the behaviors of doctors and patients, that 60% (or 70%, or 80%, or some other very high proportion) of all healthcare expenditures are made during the last six months of life. This axiom is usually stated with a high degree of indignation, as if doctors can always tell when some Old Fart is fixing to die, whereupon they say to themselves, “This old guff is not long for this world, so if we’re going to make any money off him by doing unnecessary medical procedures, we’d better get a move on.”
And while there are undoubtedly unscrupulous doctors who take this attitude, the real reason a lot of money is spent in the last few months of life is: people often are very sick during the weeks and months prior to death. And when people are sick, they and their families expect, and doctors believe their duty is to provide, efforts to make them well.
Quite often, even in old people, these efforts are successful – sick people will recover to some reasonable semblance of well-being. Often enough, even very old people who look very sick will recover with appropriate care. And in fact, unless the patient has some obvious, irreversible terminal illness – such as widely metastatic cancer that has failed to respond to therapy, or end-stage heart failure – doctors usually cannot tell with any real precision when somebody has entered into that famous “last six months of life.” The only real way to tell is retrospectively.
But when you are trying to cut healthcare costs, the retrospective method will simply not do. You need to devise a prospective method for not wasting all those “last-six-months” healthcare expenditures.
It is my suspicion that the ultimate method of doing so is going to be the age-75-cutoff-method. That is, once you hit 75, any serious illness you may develop after that will be an indication that your six-month-clock has started, and the efforts of your healthcare professionals will turn away from helping you to recover, and toward helping to usher you into the next life as humanely as possible. (After all, there will be no randomized clinical trials proving that the treatment for your condition in people your age improves the overall survival of the group.) I believe that the evidence provided so far by agents of the Central Authority point pretty clearly in that direction; that is, that end-of-life healthcare will be initiated the moment you need any significant healthcare services after age 75.
The beauty of the age-75-cutoff-method is that it will prove to be a self-fulfilling prophesy. That is, if you withhold medical care for elderly patients who are very sick, there is a very high likelihood that they will indeed die very soon. And by tabulating your statistics, before long you will be able to claim that, as a matter of fact, you can determine when that terminal six-month-clock has begun. The ability to determine this milestone prospectively will open up all sorts of opportunities for cost savings.
Our Progressive leaders are probably quite frustrated that our culture has not yet advanced enough that they can simply impose the age-75-cutoff method overtly, today. But they are not just sitting idly by. They are doing everything they can to encourage us Old Farts to “voluntarily” forgo healthcare services.
On January 1, 2011 (that is, on New Years Day, a holiday which many Americans spend in a condition that – thanks to the revels of the previous night – renders them relatively unlikely to pay attention to press releases), the White House announced a new policy that would have paid doctors for discussing end-of-life planning during their Medicare patients’ annual “wellness visit.” Under this policy, physicians would be paid to encourage their patients to establish an advance directive, which would guide medical care if the patient became incapacitated from illness, and could no longer make medical decisions for him/herself.
But just a few days later, the new policy was suddenly revoked. It was revoked, officials lamely explained, because it had not been implemented using the approved procedures. But, as anyone would know who watched Congress make Obamacare the law of the land, this could not possibly have been the real reason.
The real reason, of course, was that – even through a New Years haze – this new policy was shaping up to unleash a firestorm. And a public firestorm threatened to energize the House of Representatives, just as it was about to be taken over by the cretinous opposition party.
As keen observers will recall, the Obamacare bill originally included similar language on advance directives. Physicians were supposed to urge their older patients, repeatedly if necessary, to establish advance directives, and their success in extracting advance directives from Old Farts was to be one of the “performance measures” by which doctors would be judged to be in good or bad standing with the Central Authority.
But then Sarah Palin said “death panels,” and a furor ensued. The provision on advance directives was quickly removed from the Obamacare legislation, as if Congress was admitting that Ms. Palin had been correct and they had been caught out. (In truth, even if you buy the notion of “death panels,” the provision on advance directives was something else entirely.) So the debacle of New Years Day 2011 was the Central Authority’s second failed effort to virtually mandate advance directives.
Obviously, advance directives are very important to our Progressive leaders.
In concept at least, advance directives are a good idea. Advance directives allow patients to establish beforehand, usually by a written document, what kinds of medical treatment they would or would not want should they fall victim to a serious, life-threatening illness that leaves them unable to express their wishes. Advance directives are supposed to work by providing guidance to their physicians, who, in their fiduciary capacity, are charged with acting in the patient’s best interest.
A well-constructed advance directive allows patients to choose to spare themselves from demeaning, undignified, painful or otherwise undesirable medical procedures and treatments, should they become incapacitated at a later date. “Well-constructed” implies that the advance directives are clearly and concisely written, that they honor the ethical and legal norms approved by society, and that they provide the physician with clear guidance.
But it is more difficult to write a “well-constructed” advance directive than might at first meet the eye. The major problems are two-fold: Advance directives often express imperfect knowledge, and they are often imperfectly expressed. These limitations mean that in appropriately exercising an advance directive, often the physician cannot follow them to the letter, but must interpret them according to the circumstances at hand.
A healthy and relatively robust individual cannot always know how he or she will feel years into the future, when illness strikes and it is time to exercise an advance directive. Every doctor has seen critically ill patients who, despite having advance directives to the contrary, unhesitatingly choose to be attached to a ventilator when the time comes, for instance, rather than face certain imminent death. So experienced doctors know that advance directives do not always indicate what patients will actually choose to do when the time to make a choice is upon them.
They also know that, while conscious patients have the opportunity to repeal their advance directives, unconscious or incapacitated patients do not.* So, in exercising an advance directive, the conscientious physician interprets that directive in light of many other factors, such as, her personal knowledge of the patient, the opinions of family as to what the patient would want done, and the chances of a long-term recovery if the therapy being considered is used. Then she will negotiate with responsible family members an approach that appears to meet the patient’s presumed desires.
*Conscious patients can repeal their advance directives in theory. However, I have personally witnessed actual doctors argue vociferously against using a medical therapy that a sick patient now desperately wants, because years ago the patient signed an advance directive expressing aversion to that therapy.
Therefore the advance directive in many cases is an important part of the decision-making process, but it is not the only part. The appropriate use of an advance directive requires the doctor to behave as a true patient advocate, to selflessly place the desires expressed in the directive in context with everything else that might affect the patient’s true and current wishes, and then make a recommendation that, to the best of his or her ability, honors those wishes.
Unfortunately, doctors can no longer act primarily as their individual patient’s advocate. Indeed, physicians are officially enjoined (by the New Ethics formally adopted by their own professional organizations) to give the needs of society at least equal consideration. And so, as has demonstrably happened with other “guidelines” in medicine, it is inevitable that advance directives will be reduced to a legal edict, which must be followed to the letter if the physician wishes to remain clear of the Department of Justice.
The likelihood that there will be no room for interpretation means that constructing just the right kind of advance directive for yourself – one that will be precisely suitable to any contingency that may occur – has become extremely difficult. If you get the details just a little bit wrong for the circumstances that actually arise, the price you pay may be very heavy. It would be better to have no advance directive at all than to have one that is misleading or ambiguous. Advance directives must be written with extreme care, and only after long, thoughtful consideration.
That is not how the Central Authority would have it, however. For many years now, the Feds, under the Patient Self-Determination Act, require hospitals to inform patients about advance directives at the time of every hospital admission, and to invite them to sign one. To say this is a less than ideal time to implement an advance directive would be something of an understatement. Asking a patient to sign an advance directive at the time of hospital admission, often by including it in the pile of routine and mind-numbing legalistic documents which patients must sign if they want to receive medical care, and often with no more guidance than that provided by the admissions clerk (who might explain, “This tells the doctors you don’t want to be kept alive on a machine like a vegetable,”) tells us something about whether the true motive for advance directives is to protect the patient’s autonomy – or as an excuse to withhold care.
Having the discussion in a doctor’s office these days, sadly, might not be much better. The Central Authority knows that squeezing what really ought to be at least a 30-minute discussion into a 10-15 minute office visit already packed with Pay for Performance requirements (while providing the added threat of punishment if the physician fails to extract an advance directive from the patient), will yield, at best, a signature on a boiler-plate document.
But despite the slap-dash method by which such a document may be implemented, it is a document whose language – when the time comes – will be exercised with all the legalistic exactitude of a contract attorney by any doctor who knows what’s good for him.
I think that Americans are right in being suspicious of the big push we are seeing to urge advance directives upon us. Invoking “death panels” in this regard is utterly inappropriate, but the end result will suffice. It is good that we have all been given pause.
Still, the concept of advance directives is a good one, and I believe most Americans might do well to have one. Despite the damage that is being done to them, I think advance directives still can be salvaged. To this end, I hereby suggest several steps we can all take in executing an advance directive that will actually do what we want it to do:
1) Don’t be pressured into implementing an advance directive by anybody whose career depends on keeping the Central Authority happy. Unfortunately, this likely includes your doctor if you are not paying your doctor yourself.
2) Don’t sign a boiler-plate document. These likely will have been drafted with the interests of the Central Authority in mind, with the help of very smart lawyers, and when these documents are called into use in all probability they will be interpreted for the convenience of the Central Authority.
3) Try to keep your advance directive from showing up in an electronic medical record. Write it yourself, and store it where your loved ones can find it when they need it. Give a copy to your spouse, your children, and perhaps (if you have a direct-pay doctor who works only for you) your physician. This way, since your advance directive will not be immediately available to hospital personnel if you are suddenly incapacitated, no unfortunate and irreversible decisions regarding the aggressiveness of your medical care can be made before your loved ones are notified.
4) Write your advance directive as a general guideline, with as few specifics regarding particular types of medical care as possible. You should assume that any type of treatment you mention in a negative light will be withheld under any and all circumstances, including circumstances you may not be aware of in which you would want that treatment.
5) You are not writing your advance directive for the doctors (it is most tragic that we can no longer trust doctors in this regard!); you are writing it to help your loved ones make the right decisions for you, perhaps despite the doctors. So your goal should be to clarify your general desires for your loved ones. Discuss your advance directive with your loved ones after you have written it, or more ideally, before you have written it. Your written words will remind them of your wishes when the time is right.
I have written an advance directive for myself that attempts to follow these rules. The document is stored at home with my important papers. My wife knows where to find it, and knows my general feelings regarding these matters. With the guidance I have provided, I trust her and my children to make these important decisions for me. For anyone who is interested, my advance directive is reproduced here:
My Advance Directive:
If I am able to communicate my wishes by any means whatsoever, then I wish to make my own decisions regarding my own healthcare. If, despite my ability to communicate, my condition makes it inconvenient to fully inform me of my situation and all my treatment options, then until such time as it becomes sufficiently convenient to do so, I want everything possible to be done to sustain my life and effect a recovery.
In the event of an incapacitating illness in which I cannot communicate, the basic guideline initially should be to do everything possible to sustain my life and effect a recovery.
After a reasonable period of time (in general, I would consider a week to be reasonable) if no progress has been made in the recovery of my mental function, and the likelihood of mental recovery is judged to be small, then withdrawal of life-sustaining care should be strongly considered. To help my wife and/or children with this decision, I would like to have an evaluation by a neurologist to help clarify the prognosis.
If improvement in my mental status has been made, then efforts to sustain my life and affect a recovery should be continued.
If at any point in my care there is a period of at least two weeks in which I am persistently unable to carry out meaningful communications sufficient to make my own wishes known (in the opinion of my family members and the neurologist), and the likelihood of mental recovery is judged to be small, then I would consider the withdrawal of life-sustaining care to be a blessing.
So. Advance directives are a very good idea, but unfortunately, have been identified by the Central Authority as a potentially powerful tool for withholding healthcare services, especially in the elderly. Even before Obamacare, certain insurers were refusing to reimburse hospitals or doctors that provided medical care that seemed to go against specific language contained in an advance directive. That, of course, was child’s play. Now that the Central Authority has gotten hold of them, advance directives will likely be treated the same way as other guidelines are now treated in medicine, that is, as edicts, and thus as vehicles for the criminal prosecution of medical personnel who deign to “interpret” them.
This means that if you wish to take advantage of the benefits which advance directives can provide, you will have to proceed very carefully.
In the summer of 2008, the Oregon Health Plan (the Medicaid plan in that state) injudiciously sent a letter to lung-cancer patient Barbara Wagner denying coverage for the expensive chemotherapy her doctor had recommended, and offering instead to cover palliative care “including doctor-assisted suicide.”
Despite the fact that there were plenty of distractions at the time (including a presidential election and the world’s economy on the brink of Armageddon), that letter unleashed an impressive public outrage. (If you have forgotten the outrage, simply Google the search terms “Barbara Wagner” and “suicide.”) Indeed, the outrage was sufficient to penetrate even the dulled sensibilities of the Oregon Health Plan’s executives. One Jim Sellers, a spokesman for the plan, admitted to ABC News that “the letter to Wagner was a public relations blunder and something the state is ‘working on.’”
It is clear that the Oregon Health Plan executives were at least a little blindsided by the general reaction to their ham-handed denial letter. Denial letters, after all, are a routine activity for health insurers, and they always list (as an aid to the patient) services which the insurer judges to be reasonable alternatives to the denied care. While in this case the denied service which Ms. Wagner sought offered some reasonable hope for prolonged survival, while the service being held out by the Oregon Health Plan as an alternative (to say the least) did not, that’s really not so much different from the content of more “routine” denial letters. The difference is one of degree, and not of substance. So, Oregon Health Plan executives must surely have wondered, “What’s the big deal?”
One must try to be understanding of such insensitivity. It is a fundamental task of health plans – whether run by Medicare, Medicaid, or private insurance companies – to deliver unpleasant news to people whose lives are at stake, and it is normal (even necessary) for those who are charged with this task either to grow thick skin or to develop the traditional indifference of bureaucrats. It is perfectly predictable that such thick skin or indifference might dull one’s ability to discern subtle differences in degree among various denials of services, subtle differences that might call for more artful phraseologies than those employed in this instance by the Oregon Health Plan. The failure to recognize the need for a more artful denial letter, Mr. Sellers appeared to indicate, was the only problem in the case of Ms. Wagner. The solution, he therefore suggested, is certainly not a substantive change in any policy, but better public relations.
Those who ran the Oregon Health Plan must have been particularly disheartened when even vocal proponents of physician-assisted suicide took pains to criticize their ill-considered denial letter. To so blatantly juxtapose the reality of healthcare rationing with the “option” of assisted suicide seriously undermines the chief argument advanced publicly by the end-of-life movement, namely, that assisted suicide is merely an individual autonomy play, and is not in any way a cost-saving tool. So even proponents of physician-assisted suicide understand that offering it up as a covered medical service at the same time you are denying potentially life-prolonging therapy is both insensitive and unseemly.
Not to mention counterproductive to their cause.
I am not a proponent of physician-assisted suicide. I have two major reasons for objecting to it. On a purely practical level, embracing and systematizing physician-assisted suicide under any healthcare system that is desperate to reduce spending on medical services will almost surely lead to some terrible abuses of the practice.
My second objection to physician-assisted suicide is based on a consideration of ethics. I will admit to being on somewhat shaky ground here because I am not formally trained in ethics, and it appears for all the world that those who are formally trained in ethics have universally concluded that physician-assisted suicide is perfectly OK in every way.
Debating with modern medical ethicists, at least if you are merely a layperson, is mostly a losing proposition. This is not because ethicists are intellectually (or even ethically) superior to the rest of us, but rather because they are adept in couching their arguments in arcane twists of logic and webs of jargon that make their arguments unintelligible to the uninitiated. This technique, of course, places novices like myself in the position of having little choice but to accept the ethical bottom line without really understanding how the bottom line was reached. It reduces medical ethicists to a priesthood, and medical ethics to received knowledge.
But advancing unintelligible ethical arguments is, well, unethical.
In any case, with these caveats I will now present my understanding of the chain of logic by which modern ethicists justify physician-assisted suicide – and its close cousin, euthanasia. I would be delighted to engage into a discussion with any ethicist who is offended by my attempt to reduce their argument to accessible English. Modern ethicists argue as follows:
Point 1: Our society has already decided that the autonomy of the individual patient is the overriding ethical consideration in making end-of-life decisions. We formalized this determination when we decided that an individual has a right to refuse medical treatment even if that treatment is very likely to save their life. Clearly, this determination means that individual autonomy is the universally agreed-upon controlling ethical precept.
And by adopting this controlling precept, we thereby have also firmly decided that passive euthanasia – allowing nature to take its course by withholding treatment at the request of the patient – is ethical.
Point 2: There is no ethical distinction between passive euthanasia and active euthanasia. That is, whether we let death occur by withholding effective medical care, or by actually doing something to help death along a bit, either way we’re taking an action that hastens death. Ethically, both of these actions are equivalent. So, once we decide that individual autonomy is the overriding concern, we must also allow for active euthanasia when a patient wishes it.
Point 3: Once active euthanasia is deemed ethical, there can be no further ethical objection to the lesser act of physician-assisted suicide. If it is ethical for a doctor him/herself to bring on the death of a patient who requests it, there can be no objection to doctors preparing the suicide machine and handing the patient the switch.
The striking thing here (to me, at least) is that in establishing the ethical case for physician-assisted suicide, we necessarily also establish – as a veritable pre-condition – the ethical case for physician-provided euthanasia. Whether the patient says, “Help me to take my own life,” or “Take my life for me,” modern medical ethics supports the physician who replies, “Roll up your sleeve.”
For those who don’t see a problem with this, I refer you to the Dutch system, where, in full accordance with modern medical ethics, the rules permit both physician-assisted suicide and active euthanasia for patients who request it. Reports on the results of the Dutch system (reports which both sides have used to bolster their respective opinions on either the glories or the travesties of such a system) do point out one striking finding – hundreds of times each year, acts of involuntary euthanasia are occurring. That is, patients are being killed under the Dutch healthcare system at the hands of their doctors, without their explicit permission or even foreknowledge. All these patients, it is claimed, are being euthanized for entirely humane reasons.
What do our friends the medical ethicists have to say about such involuntary euthanasia? Well, it turns out that it’s OK with many if not most of them. Ethicists don’t like to tell us that their chain of logic doesn’t end with Point 3. Once we make the principle of individual autonomy the overriding consideration in determining end-of-life ethical issues, the same chain of logic takes us directly to Point 4.
Point 4: Since honoring the ethical precept of individual autonomy makes voluntary euthanasia available for patients with intractable suffering, it would be unethical to withhold the same benefit from suffering patients who are too incapacitated to give their permission. Their incapacity should not restrict them from a good that is available to others, for to do so would be discriminatory and inhumane. To cure this problem, the boon of active euthanasia can and must be performed, even without the patient’s explicit permission, in incapacitated patients whom “reasonable people” would agree are suffering too much. Therefore, involuntary active euthanasia is also ethical.
This conclusion, of course, leaves us in a place where others (i.e., “reasonable people,” like doctors or other agents of the Central Authority) can decide for an individual what constitutes intractable suffering, and further, can decide when such an individual is simply too incompetent to know that euthanasia is the best thing for them.
I maintain that under our system of covert healthcare rationing, where doctors are under extreme pressure to do the bidding of the third party payers (both private insurers and the government) who determine their professional viability, and where the payers are under extreme pressure to reduce costs, and have already displayed in numerous ways their willingness to permit suffering and death among their subscribers in order to do so, then opening the door for physician-assisted suicide (let alone physician-administered euthanasia, whether the patient requests it or not), would inevitably lead to some nasty abuses, and would ultimately serve to undermine our civil society. I am too politically correct to use the “other N-word,” but I will take this opportunity to remind you that such a thing has already happened, in a country that boasted the world’s most advanced, cultured and educated people, within the memory of millions of living people.
I believe that the principle of individual autonomy is vitally important. Indeed, it is the founding principle of American culture. However, no single ethical principle, no matter how important, can be allowed to overrule all other ethical principles in all other circumstances. By nature ethical precepts are often in conflict with one another, creating what is called an ethical dilemma. And (I humbly submit) it is supposed to be the job of ethicists to help us work through those ethical dilemmas, to find the right balance between competing principles, and not to simply declare that no dilemma actually exists, because Ethical Precept A is the only one we need to pay attention to.
Individual autonomy is critically important to American culture, and the fact that we must fight to preserve individual autonomy in the face of Progressive healthcare is indeed a chief underlying theme of this book. But in no other aspect of our culture do we let it absolutely rule. The autonomy of individuals needs to be checked, and we indeed limit it. This is the fundamental reason that governments are necessary in the first place.
The reason we have laws (supposedly) is to make sure that the behavior of individuals acting in their own interest, especially those who have accrued power (for instance, by accumulating great wealth, by acquiring large weapons, or by becoming heads of state), does not abrogate the natural rights of other individuals. Indeed, most of the political fights we have – between Democrats and Republicans or Progressives and Conservatives – are to determine where to place those limits, on individuals and on the collective, to best encourage a robust society that honors individual autonomy but that also encourages reasonably equal opportunities for individual fulfillment (i.e., “happiness”). The main purpose of our public discourse, then, is to find the right balance between the rights and needs of individuals and the rights and needs of society as a whole.
So for ethicists to say, “Individual autonomy is all there is to it, and we have no choice but to follow that principle to wherever it may lead us,” is not only completely irresponsible and dangerous, it also flies in the face of our culture’s history and our everyday experience. The cost to society not only should but must be taken into account as we consider institutionalizing physician-assisted suicide (let alone voluntary or involuntary euthanasia). In my opinion, ethicists who argue that we need not consider the cost to society in making end-of-life policy have declared themselves unworthy of the title and they ought to be completely ignored.
The cost to our society of institutionalizing and systematizing physician-assisted suicide, especially while we are still covertly rationing healthcare, would be severe. The cost would be paid in the currency of a further devaluation of human life, and a potentially fatal coarsening of our culture.
So far, those pushing assisted suicide insist that they are doing it to preserve individual autonomy and human dignity. And no doubt, many of these voices are entirely sincere. For the most part our Progressive leaders to this point have been content to sit on the sidelines, and let these sincere end-of-life advocates do their work for them. But every now and then our leaders’ enthusiasm for the potential cost savings that might be realized through the widespread adoption of assisted suicide bubbles to the surface.
The letter the Oregon Health Plan sent out to Ms. Wagner is one such example.
Here’s another example. Writing in The American Journal of Economics and Sociology as long ago as 1993 (the last time Progressive healthcare reform was prominent), professor K.K. Fung pointed out that the healthcare system could save a lot of money by creating incentives to induce sick patients to commit suicide, with the help of their doctors. He blandly called his plan “physician-assisted suicide with benefit conversion.” Under this plan, patients (or rather, their estates) would be paid a nice, tidy sum – calculated as a percentage of the projected cost savings the healthcare system would realize thanks to their self-termination – to opt for a painless and dignified death at the hands of their physician.
Physician-assisted suicide as an occasional and extraordinary solution to a rare, intractable clinical dilemma is one thing; institutionalized and encouraged as a routine healthcare option it is quite another. It is not difficult to imagine the promotion of assisted suicide as an attractive choice that any really sick person ought to consider. TV commercials, pop-up ads, and even pamphlets included in your hospital admission packets will remind you that you always have the option of saving yourself, at a time of your choosing, from the suffering, pain, needles, knives and scans with which the healthcare system likes to torture sick people. You have the means of taking control of your own destiny, asserting your autonomy, and removing yourself to a place where, free from all the pain, and enveloped in peace, you can be gently eased into the next life. You no longer have to worry about being a burden to your family and loved ones (or to the collective). You have it within your power to do one last thing for yourself and for the people who care about you. It’s your choice, you are told lovingly – and expectantly.
And even if you choose not to listen to this stuff, your children and your grandchildren will. Whether or not they come right out and say it, you’ll know what they’re thinking: “Well, it’s sort of getting to be about that time, isn’t it?” And before you know it, your option for assisted suicide will become your duty for assisted suicide.
Furthermore, you should ask yourself whether the Central Authority can really stay its hand for very long when it is facing fiscal oblivion, and at the same time it has both the ethical cover and the capability to direct its agents at the bedside (i.e., your doctor) to perform euthanasia on unfortunate (and unproductive) citizens such as yourself, who are too “incapacitated,” or too damned selfish, to understand it’s the only thing to do.
When all is said and done, it is deeply ironic that by steadfastly clinging to the ethical precept of individual autonomy to guide end of life healthcare we will very likely completely devalue the inherent worth of the individual.
This outcome, really, demonstrates that our reliance on individual autonomy is in fact not the pinnacle of ethical thought; rather, it is a palliative, a partial and ultimately inadequate (though necessary) compensation for having to live in an imperfect world. Indeed, the attractiveness of Progressivism – the reason so many well-meaning people gravitate to it – derives fundamentally from its recognition of the inherent limits of individual autonomy as an organizing principle.
Especially as we face our final exit from this imperfect world, the palliative of individual autonomy loses much of its significance. To throw all other considerations to the wind, to make some ideal notion of the dying person’s autonomy the overriding concern, ignores reality, ignores the other things the dying person needs more than his autonomy, is harmful to society, and calls into question our real motives. Encouraging a rapid exit is no way to honor a dying person’s individual worth. There are far more important things we should be doing for the dying patient. We should offer relief from physical and emotional pain, offer help in resolving remaining issues of family or personal conflict, and offer spiritual support. We should let the dying person know that we will not abandon him, that we are embracing him, and not hastening to move him along to the final exit as quickly as we can. It is by such an affirmation of that person’s continuing importance that we really honor his value as an individual.
Finally, I am compelled to point out that modern medical ethicists insist on clinging so tenaciously to the precept of individual autonomy only when it comes to end-of-life healthcare, that is, only when doing so happens to justify inducing the expeditious and efficient deaths of inconvenient Americans. In all other questions regarding medical ethics – for instance, the practice of one-size-fits-all herd medicine; the adoption of New Age Ethics by the medical profession, which commits doctors to act primarily for the collective instead of for the individual patient; and the stifling of the individual’s prerogative to defend his own health with his own resources – these ethicists totally abandon individual autonomy in favor of achieving “social justice.” They are, in other words, utilitarians, who invoke “individual autonomy” only when it suits their desired end, that end being the devaluation of the individual for the benefit of the collective. Ultimately, the ethicists’ devotion to individual autonomy at the end of life is entirely cynical.
At least until we solve the fiscal problems of our healthcare system, we simply should not embrace assisted suicide – no matter what we may think of the ethics of the act itself – and we should fight efforts to make it acceptable. Once it is acceptable, the fiscal pressures will soon systematize it, and render it nearly mandatory. And the real cost to our society would be profound.
If people want to commit suicide and if medical ethicists insist that assisted suicide is OK, then let the ethicists do the assisting. I have relatively little to say against ethicist-assisted suicide. But for the love of God keep the healthcare system – and especially the doctors – out of it.
In the next chapter I am going to talk about conflicts of interest within the healthcare system. This has become a hot topic in recent years. And when this topic comes up, it is always framed as a problem of physicians, and drug companies, and medical device companies, all of which may often stand to gain when some product or procedure is recommended for a patient.
But the biggest conflict of interest of all does not involve doctors or the biomedical industry. It involves the Central Authority.
The Central Authority, under our Progressive healthcare system, is to become the ultimate arbiter of who gets what medical services and when. At the same time the Central Authority is facing an existential fiscal crisis, a crisis primarily caused by healthcare expenditures. Therefore the need to cut costs, and specifically the need to withhold healthcare services whenever it can be gotten away with, will necessarily override all other considerations. This is a conflict of interest.
Given this conflict of interest, what does the Central Authority see when it sees an elderly person?
1) It sees a person whose intrinsic value to the collective is vanishingly small, as documented in Dr. Emanuel’s 2009 Lancet publication.
2) It sees a person who, by virtue of age, is either consuming a tremendous amount of healthcare resources, or soon will be.
3) It sees a person who, each month, is collecting a Social Security check; that is, who is continuously taking away some of the Central Authority’s precious resources, which could otherwise be applied to its critically important work.
4) It sees a person who may very well have accumulated a sizable IRA or 401(k), and who, each month he or she continues living, is frittering more and more of that money away on golf or Jazzercise. Assuming that Progressives succeed in reinstituting a sizable death tax, the elderly person who, by virtue of remaining alive, continues spending down his 401(k) is in essence stealing funds that are earmarked for the Central Authority.
Talk about conflicts. We Old Farts don’t stand a chance.
From every indication the Central Authority is giving us, the age-75-cutoff looks real. At the very least, the Central Authority has determined that in this age group cancers should go undetected. It seems at least plausible that steps will be taken, likely tacitly, to institute a “last-six-months clock” for people over 75 who become seriously ill. Once that clock is started, aggressive and potentially curative care will be left aside (along with optimistic talk), in favor of palliative care and crepe-hanging. Advance directives – which will have been wheedled out of most of us by our doctors – will be enthusiastically invoked and followed to the letter with the strictest interpretation possible, and (ultimately) assisted suicide will be broached to us, circumspectly at first, but soon enough (as we begin to understand the futility of our position) with increasing urgency.
Laugh if you will, Whippersnappers. Soon enough, all this will be yours.