Brain-Jockey

Duty to Die: Is It Plan B?

Written by Audrie Zettick on May 21, 2009

Some say 70 is the new 50.  I say if we are not careful, 2009 may be the new 1984 and seniors may have much to worry about.  So far this year, we’ve had federal policymakers begin to dictate what we can and cannot drive, seek to inject government into labor contracts via the Employee “Free” Choice Act, and express their desire to explore ways to make “reasonable mandatory service requirements“ for young people.  Can dictates about health care be far away?

 

You may know our health care system needs some tweaking–you know costs seem out of control–but you’re quite happy with your own employer-provided health care plan.  Maybe–despite being quite intelligent–it just all seems too complicated to pay much notice.

 

Time to notice. This will affect you in some way.  And it’s likely to come sooner than later, as Congressional Democrats are working under a self-imposed July 31 deadline for passage of any health care reform.

 

Proposals from Left to Right 

 

Proposals run the gamut and are under constant development.  On the far left, we have those of the liberal bent (exemplified by Rep. Peter Stark) who, in search of universal health care coverage, carve a large role for a government-provided plan, even automatically enrolling all newborns.  On the center left, we have proposals like the Democrats’ mandated insurance proposal, where a requirement to have health care would apply to individuals and employers would be required to foot more of the bill.  Tax penalties apply to those who don’t comply, and the government takes on an increasing role in setting insurance rules.  Somewhere in the middle are plans like Sen. Wyden’s, which recognize that the private sector must play a large role.  On the center right, we have the Republicans, whose just-released proposal is heavy on consumer choice, with a touch of reality-driven government regulation.  On the far right are proposals that leave total choice up to the consumer, through expanded options like health savings plans–already available to many if they hold a high deductible insurance plan and health .   

 

Duty To Die

 

President Obama has laid out 8 principles of health care reform that on their face appear balanced, but his 3 bedrock principles leave much wiggle room, and lead with Cost Containment.  I can’t argue with cost containment in principle, as a former small business owner who watched our health plan premiums skyrocket.  But with Obama’s health care plan estimated to start at $634 billion and rise from there, there is extreme pressure for cost savings.  I’m concerned that any effort to control costs doesn’t digress into a public policy where government makes the choices about significant aspects of our health care.  

 

The stimulus package already included a favorite of President Obama–Comparative Effectiveness Research–designed to rein in costs to allow expansion of health care coverage for all.  Used correctly, a database of most effective treatments could be a godsend to doctors and consumers alike.  In the hands of a government-run health care program, it could slip into a cost-saving debacle, denying options and coverage to consumers.  Some speculate that the elderly would bear the brunt of this approach. 

 

It’s a real issue, since Duty to Die is a real philosophy, discussed in many ethics textbooks and proposed by respected academics (see here and here ).  While some scoff that critics are misrepresenting Comparative Effectiveness Research, it’s wise to watch for the slippery slope, since some experts have specifically suggested the following:

 

•  “there is a moral duty to die inexpensively in healthcare contexts.” J. Angelo Corlett, Professor of Philosophy,  Health Care Analysis, “Is There a Moral Duty to Die,” Nov. 2, 2004.  Corlett based his theory on Paul Menzel’s theory of health care distribution (Menzel is author of “Strong Medicine: The Ethical Rationing of Health Care”)
• “Even very young children can understand that medical costs can quickly absorb money that could otherwise be put aside for college education or a family vacation, for example.”  (Judith Lee Kissell, PhD; professor of bioethics)

 

To this genre of  philosophers and bioethicists, the duty to die is social policy–based on a view that medicine can be used as a mechanism for a more equal distribution of wealth and resources. 

 

This is a departure from other physicians who discuss this issue of limited resources.  When discussing medicare funding challenges, doctor Kenneth Prager is more measured, recognizing the challenge of limited resources, but noting that the “proper approach to an aging population that consumes ever more health care dollars is not to cut their access to care arbitrarily but to develop a multifaceted approach that emphasizes patient and physician education about what medical care is helpful and what is not…”

 

What’s Already In Place

 

Worry not, you say.  A federal Duty-to-Die policy would never happen.  Perhaps not. The Stimulus Bill created a Federal Coordinating Council for Comparative Effectiveness Research.  Original language was changed to insert words like “clinical” and eliminate any references to cost control because of an outcry regarding these issues.  I agree with Media Matters that the stimulus bill never contained language dictating that knowledge about Comparative Effectiveness be used to prohibit certain treatments.  HHS says that ”The Council will not recommend clinical guidelines for payment, coverage or treatment.” Specifically, the Stimulus Bill says: “Nothing in this section shall be construed to permit the Council to mandate coverage, reimbursement, or other policies for any public or private payer.”  Call it semantics, but when we use the term “mandate” we usually mean things the government requires us to DO, not what they don’t allow us to do. 

 

Semantics aside, it would be entirely possible for another government entity–tasked with cost containment–to take the data compiled as a legitimate part of comparative effectiveness and use it to craft other cost-containing policies that limit coverage.  This is more tempting to invoke the tighter the U.S. gets squeezed by health care coverage costs.

 

Do the Math

 

The Council is modeled after Tom Daschle’s references to a U.K board–The National Institute for Health and Clinical Effectiveness  (hat tip Betsy McCaughy at Bloomberg) which “approves or rejects treatments using a formula that divides the cost of the treatment by the number of years the patient is likely to benefit. Treatments for younger patients are more often approved than treatments for diseases that affect the elderly, such as osteoporosis.”  This is known as Quality Adjusted Life Year calculations.

 

Couple this health care framework with statements about saving money,  and we’re closer to the slippery slope.

 

I have a 91 year-old-grandfather who wielded a table saw last summer to help with a home project and still drove (safely…really) until last month, when a sudden onset of cataracts limited his mobility.  Would a government bureaucracy tell him he couldn’t have his cataract surgery this month, because after all, it makes no sense since he’s near the end of life? If the cataracts had come on at 85 or 89, would a decision have differed?  Health care decisions need to be made on a case-by-case basis.  

 

I’m not the only one concerned with putting road blocks in place to prevent a slide to Duty to Die.  A group of moderate, business-oriented Democrats just release their own proposal –H.R. 2505–to reshape Obama’s Federal Council, now composed entirely of Federal bureaucrats.  The goal of their Council would be to ensure that “medical decisions remain between physicians and patients.”  Even former Congressman Tony Coelho — chair of the Partnership To Improve Patient Care and certainly not a conservative–voiced his worry that cost containment will become the main goal of the Federal Council in its current form.  While this legislation contains some language regarding examining health expenditures associated with a “health condition or the use of a particular medical treatment, service, or item,” the remaining language makes it clear this new nongovernmental Council would focus on patient health and well-being, and the quality of care.  I view this bill as a guardrail to prevent health care reform (in whatever form) from careening off the cliff and down the slippery slope.

 

Health care reform is too important to leave the details to Washington without our voices being heard.  Regardless of the ultimate shape of health care reform, we must make certain “Duty to Die” never sees the light of day, setting roadblocks in the way of health care rationing.