August 11, 2009
Will Section 1233 Hasten Patient Deaths?
Critics concerned that health care bill offers doctors incentives to have "end of life" discussions and report back to the government.
In its face, there is nothing wrong with the government encouraging doctors to have end of life discussions. After all, doctors are notoriously bad at having those discussions and following through on the decisions reached. (In one major study, "only 47% of physicians knew when their patients preferred to avoid CPR; 46% of do-not-resuscitate (DNR) orders were written within 2 days of death.")
So, the provision in the health care bill currently in the House, called Section 1233, is not really a big deal. It asks doctors of Medicare patients to have end of life discussions every five years or sooner if they are diagnosed with a terminal illness. It asks doctors to report what was discussed and the decisions reached, which can be perceived as an intrusion into patient privacy but also makes sense if the government is interested in making sure the money is well spent.
However, as Jay Sekulow, chief counsel for the American Center for Law and Justice, points out in this NPR interview what may be an otherwise helpful suggestion from the government is, in the middle of a health care bill designed to cut costs, extremely dangerous. In the context of cutting costs, Section 1233 looks more like the government is asking doctors to do the dirty work of "bending the curve" of health care costs by convincing the elderly to forego medical care.
Sekulow is not the only one concerned. Charles Lane writes in the Washington Post, "Section 1233 dictates, at some length, the content of the consultation. The doctor 'shall' discuss 'advanced care planning, including key questions and considerations, important steps, and suggested people to talk to'; 'an explanation of . . . living wills and durable powers of attorney, and their uses' (even though these are legal, not medical, instruments); and 'a list of national and State-specific resources to assist consumers and their families.' The doctor 'shall' explain that Medicare pays for hospice care (hint, hint)."
Figures vary as to how much could be saved on health care costs by providing palliative treatment for end-of-life patients instead of aggressive care, though I've read studies that show hospice patients survive longer, on average, than patients with aggressive treatment.
Still, elderly patients--along with the obese--are a tempting group to try to wring costs from. If the culture moves toward more palliative care at the end of life, it will be interesting to see if Christians respond with an outbreak of vitalism--the extension of life at all costs--for which there is a strong tendency among evangelicals accustomed to pro-life arguments.
Or, possibly, Christians will take the opportunity to rediscover the art of dying--the Christian practice that did not teach the pursuit of extended life at any cost, but rather taught the willingness to die, exhortation to the living to receive the lessons taught by the dying, the expectation of bodily resurrection, and hope in the entrance into life with God.