End-of-Life Counseling Back from the Dead

Welcome to Politics Bites, where every afternoon at It's a Free Country, we bring you the unmissable quotes from the morning's political conversations on WNYC. Today on the Brian Lehrer Show, medical ethicist Daniel Callahan and journalist Trudy Lieberman discussed a new federal policy that will allow the government to pay doctors to discuss options for end-of-life care with their patients.

Politifact.com’s “Biggest Lie of 2009” is back, in a way.

During the health care reform battle, the phrase “death panels” was used to describe a provision in the bill that would fund end-of-life counseling. That language was eventually removed from the legislation, but through some recent federal rulemaking, the government has decided that next month it will begin paying doctors to discuss end-of-life options with their patients.

Taken collectively, these options are called an “advance directive,” and include things like a living will, whether or not you have a health care proxy, and organ donations. Trudy Lieberman says that these decisions shouldn’t be made lightly.

I think it’s important to remember that it’s really important for people to have these discussions, and I think that importance got totally lost in all that “death panel” business that was going on and the political hysteria that accompanied it. We in the consumer business have always recommended that people have this discussion, and it’s an uncomfortable one. Nobody wants to think about the end of their life and nobody wants to discuss this with their families, but it’s better to think about it than to have your family worry about something at the end.

Both Lieberman and Daniel Callahan said that end-of-life counseling is a necessary good, but Callahan pointed out that the recent debate about who should be paying for it has drawn attention to a major trend in how Americans treat health care.

In our country, culturally, we have a bias toward spending as much as we can at the end of life to prolong life. This is what we, as America, sort of like. That’s been called into question certainly during the health debate and before that, about the money being spent at the end of life and is it worth it.

That concern is relatively new, according to Callahan. With ballooning costs and a struggling economy, legitimate worries about the affordability of such a service have eclipsed the need for elder care in the eyes of many politicians. For decades, Callahan said, it’s been the other way around.

To me, what’s remarkable about the recent turn of things is that for 40 years, there’s been practically no controversy whatsoever about this issue, left or right, everybody agreed patients should have more choice, doctors should be better educated…so a lot of things were started and put in place and there was very little dissent. And somehow this issue got caught up in the other health reform debates and I think a lot of the confusion was in part a confusion between issues of end-of-life care and the rationing of end-of-life care.

Regardless of whether counseling is covered by the government or not, or whether you even make use of it, Callahan insisted that you’re better off having an advance directive than going without one.

If you don’t have an advance directive you are pretty much at the mercy of the physician that takes care of you, and that may be a physician you have never met before in your life, in an emergency room or an ICU, and in that sense you are really quite vulnerable to the ethic of the hospital, to the ethic of the physician. Plus, I’d mention physicians are paid to do things to you, so you’ve got financial incentives working against the good conversation. If you’ve left no directions, you better hope you have a very good and sensitive doctor.

When asked if the federal government’s move to fund counseling is an example of backdoor democracy, since it was a policy that had been removed from accepted legislation, Lieberman said that it’s the kind of thing our government is always doing. What’s most important is that we know about it.

There’s rulemaking going on all the time in the federal government. The issue is we need to be looking at those rules and finding out what’s going to happen and reporting on them. They kind of did this on the quiet hoping they wouldn’t have the...backlash, and they did it during the holidays when people aren’t paying as much attention, but we need to be looking at those rules.