The Death Panel's Loving Embrace

The House Republicans' vote to repeal ObamaCare's Independent Payment Advisory Board played nicely into the Democrats' health care shell game by implying that the law's "death panel" provision is a detachable appendage, when in truth death panels are of the essence of government-controlled health care.  For a core principle of socialized medicine, whether in its advanced or incipient form, is, and must be, the rationing of human life.

The fundamental distinction between private and government-controlled health care is a difference in the decision-making interests driving the two systems.  In a private system, consumer demand drives the provision of services.  The patient -- either directly, or, if necessary, through his family -- delivers his requirements to the market, and service-providers compete for the privilege and profit of satisfying his needs to the best of their ability.  If they serve him well, they make more money.  The individual patient's interest in his own self-preservation is thus the initial motivating factor.

In a government-controlled system, the situation is reversed.  The service provider's interests are primary, and those interests, since they are unencumbered by profit concerns, need not take into account the interests of any individual patient.  Furthermore, since the argument for government-controlled health care is always a variation on the theme that health care is too important to be provided on the basis of the patients' ability to pay, such systems begin with a bias towards treating all patients "equally" -- i.e., generically.

The difference between the motives driving the two types of medicine becomes clear in so-called "end-of-life" situations -- i.e., situations wherein life-threatening illnesses appear incurable.  In a private system, the hospital would have a vested interest in preserving the patient's life as long as possible, by whatever means the patient or his family is prepared to pursue. 

In a "public" system, these situations, which, taken collectively, constitute the bulk of health care expenses, run up against budgetary concerns.  And the system's budget is inextricably connected to political considerations involving tax rates, bureaucratic inefficiencies, and so on.  Add to this the fact that a socialized, generic program systemically detaches medical professionals from any vested interest in the survival of individual patients, and you have a recipe for pragmatic cost-shaving at the level of life-preserving services provided to Grandma.  In short, "death panels" become the essential pressure-release valve of such a system.

Some American advocates of socialized medicine are refreshingly honest about this inevitability.  (Witness Robert Reich and Bill Gates, for example.)  Those currently in political office, however, are quick to express outrage and indignation at these "death panel" accusations.  And their protestations sound almost reasonable, as long as we envision the end-of-life budget bureaucracy as a cabal of Mengele-like demons, chuckling coldly as they crunch the numbers on this week's list of disposables.

In truth, the death panel is less an embodied reality than an underlying argument: government-funded health care must cut costs; inordinately high costs are incurred in treating patients nearing the end of life; therefore, such patients must be hurried along somehow, in order to save money.  This argument, a tad too brutal for modern sentiments, requires a corresponding rationalization.  Necessity is the mother of invention, however.  Thus, the need created by the economics of socialized medicine has given rise to the invention of an appropriate, and appropriately Orwellian, rationalization, by way of the new specialty, "end-of-life care."

Modern "hospice care" was founded in Britain during the 1960s by Dame Cicely Mary Saunders.  "Ideally," Saunders said, "the doctor should remain the center of a team who work together to relieve where they cannot heal."  (Leave aside, for the moment, the loaded words "cannot" and "relieve" in that statement.)  Central to the founding idea, typical of British medicine, was that this service should be "free" to everyone -- all well and good, as long as Dame Saunders' project was being funded primarily through private donations.

From this seemingly noble, innocent origin -- symptom relief for the dying -- hospice care developed into "palliative care," a name invented in 1973 by Canadian Balfour Mount.  Alongside this evolution, often at odds with it, arose an increasingly bold faction of "death with dignity" and euthanasia advocates. 

Gradually, the new specialization was swept up in the fiscal realities of government-funded health care, until the bureaucratic number-crunchers, with support from the new academic cottage industry called "bioethics," contrived to turn palliative care into a primary mechanism of cost-reduction in socialized health care -- while providing sufficient rationalization to convince decent humans to perform this function in good conscience.  Palliative care today provides moral and political cover for those who are not prepared to promote active euthanasia, but who nevertheless feel that it can be objectively determined at what point a person has run out of reasons to live (aka social value) and can therefore be hustled out "with dignity" -- i.e., efficiently.  In short, palliative care becomes a de facto death panel.

Predictably, the most "advanced" palliative care programs exist in nations with the most advanced socialized health care systems, the exceptions being those less sentimental socialist nations in which more aggressive forms of "palliation" are practiced openly.  Among developed nations, a recent report on palliative care singled out three countries for criticism as having "inadequately" developed programs: America and Singapore, which have the most market-related (i.e., patient-driven) health care systems, and Japan, which has the world's longest life expectancy.  Go figure.

How does this sentimentalized cost-cutting mechanism work?  I offer, as a case study, the example of an elderly relative of mine, who died in a Canadian Catholic hospital several years ago.  As it happens, her hospital was a few blocks from my home, so I was privileged to be with her several hours a day during her final weeks, and I can therefore recount the nature of her care very specifically.  (Any honest observer who has lived in a socialized health care system has seen many variations of this case, but let's keep it simple.)

This patient was an 85-year-old widow suffering from kidney failure, along with other chronic problems.  She was mobile, and mentally sound.  One day, while she was still undergoing active treatment, she was paid a visit by a pleasant and professional lady dressed in a Hillary-style pantsuit.  This was the palliative care doctor.  She seemed very keen to have the patient's relatives present at this meeting, and she gave every indication of wanting to help the entire family through the coming days.

Her message, delivered very carefully and deliberately, was twofold: first, to the patient, she politely conveyed that in order to receive the necessary care, returning home ("to die" is the unspoken completion of that phrase) was not an option.  Pain relief, alleviation of distress, and so on were available only if the patient remained at the hospital.

Secondly, and with the finesse of a surgeon, the doctor reassured the family that she wished to guarantee that the patient was in control of her own pain-control regimen until the last.  This, she explained, required that the family accept that, henceforth, all decisions must be made by the patient in conjunction with the palliative care doctor.  This exclusion of the family from the decision-making process was explained with the tenderest reasoning.  Because we loved the patient, and did not wish to lose her, we had a vested interest in keeping her alive and conscious at all costs.  But this might cause us to act against the best interests of the suffering patient.  Thus, in order to spare her unnecessary pain, we must be willing to give up our self-interested desire to have a say in her care.  That's right: Dylan Thomas' plea to his father to "Rage, rage against the dying of the light" is now dismissed by right-thinking liberalism as the cry of petty self-interest.

Subsequently, the patient was moved across the hall to a palliative care room, where her "end-of-life care" began in earnest.  Several times each day, nurses came in to ask her whether she was in pain.  Each time, she said "no," and each time the nurses tried to persuade her to avail herself of the powerful medication the doctor had put on standing order for her -- even though she was experiencing no pain.  It was obvious that the nurses were under instructions to get the patient onto an aggressive pain-relief regimen as quickly as possible, regardless of need.  A patient on increasing doses of such medication is quicker to lose mental focus and the will to eat, both of which results are triggers for taking the "palliative" measures to the next level. 

The patient, who happened to have been a nurse herself, at this very hospital, understood the game all too well, and she requested the precise identity and purpose of every pill she was given.  The nurses actually managed to coax her into submitting to a dose of the unwanted pain medication on a couple of occasions when no family members were present.  The effects were severe.  As a result, she became increasingly insistent on having someone with her each time a nurse or doctor visited.  In fact, apart from the fear of death, which this woman handled with a courage I can only envy, her main worry in her final days concerned what the nurses were trying to push on her on an hourly basis.

As the days passed into weeks (weeks spent talking with family, trying to solve old problems, and praying -- think of what those weeks would mean to you), it was clear that the professionals were becoming increasingly perturbed about the occupancy of this bed, which would be needed by other "end-of-life" patients soon.  They were also frustrated by the incessant presence in the room of family members -- interested observers throw a wrench in the works.  (The immediately previous occupants of this "end-of-life" room had had few visitors -- and had died quickly, as they were "supposed to.")

When she had taken a sleeping pill, or was feeling particularly weak, the nurses would come in regularly to test her alertness.  As soon as she demonstrated some loss of mental faculties, you see, the palliative care team would, according to the arrangement, take over her "pain relief" directly.

On the patient's final night, my wife and I were with her.  Kidney failure had weakened her terribly, and her mind was slipping.  She frequently faded in and out of contact with her surroundings.  Knowing her wishes, we hoped against hope that somehow the nurses would fail to notice her deterioration, and she would be allowed to complete her journey on her own terms.  Unable to stay focused, she said silly things, in the manner of one half-dreaming. 

We tried to rouse her near the time the nurse was due to arrive with the evening's medication, but we couldn't keep her alert.  The nurse came, and began aggressively testing for signs of confusion.  By some extraordinary act of will, the patient sat upright and answered the nurse's questions correctly, as well as volunteering a detailed description of the dosage of medicine her doctor had permitted her.  As the nurse left, somewhat bemused, it was clear that our beloved patient knew exactly what she had just done -- what her brilliant performance had won her.

Two hours later, on her terms, she died.  She had outwitted the death panel.  Would that everyone could be so lucky.  Would that everyone could be spared the indignity of being herded prematurely into "death with dignity."  Would that everyone could be spared socialized medicine, and its inhuman cost-benefit analysis.

In the report cited above, Tony Nash, a leading palliative care advocate, and author of the international "Quality of Death Index," criticizes U.S. health care this way:

The focus is on curative care, where doctors focus on curing patients at all costs; the U.S. is an extreme example of that.

Not extreme enough, I fear.  The 2012 election is literally a matter of life and death.  In socialized medicine, the death panel comes disguised as a loving embrace.

The House Republicans' vote to repeal ObamaCare's Independent Payment Advisory Board played nicely into the Democrats' health care shell game by implying that the law's "death panel" provision is a detachable appendage, when in truth death panels are of the essence of government-controlled health care.  For a core principle of socialized medicine, whether in its advanced or incipient form, is, and must be, the rationing of human life.

The fundamental distinction between private and government-controlled health care is a difference in the decision-making interests driving the two systems.  In a private system, consumer demand drives the provision of services.  The patient -- either directly, or, if necessary, through his family -- delivers his requirements to the market, and service-providers compete for the privilege and profit of satisfying his needs to the best of their ability.  If they serve him well, they make more money.  The individual patient's interest in his own self-preservation is thus the initial motivating factor.

In a government-controlled system, the situation is reversed.  The service provider's interests are primary, and those interests, since they are unencumbered by profit concerns, need not take into account the interests of any individual patient.  Furthermore, since the argument for government-controlled health care is always a variation on the theme that health care is too important to be provided on the basis of the patients' ability to pay, such systems begin with a bias towards treating all patients "equally" -- i.e., generically.

The difference between the motives driving the two types of medicine becomes clear in so-called "end-of-life" situations -- i.e., situations wherein life-threatening illnesses appear incurable.  In a private system, the hospital would have a vested interest in preserving the patient's life as long as possible, by whatever means the patient or his family is prepared to pursue. 

In a "public" system, these situations, which, taken collectively, constitute the bulk of health care expenses, run up against budgetary concerns.  And the system's budget is inextricably connected to political considerations involving tax rates, bureaucratic inefficiencies, and so on.  Add to this the fact that a socialized, generic program systemically detaches medical professionals from any vested interest in the survival of individual patients, and you have a recipe for pragmatic cost-shaving at the level of life-preserving services provided to Grandma.  In short, "death panels" become the essential pressure-release valve of such a system.

Some American advocates of socialized medicine are refreshingly honest about this inevitability.  (Witness Robert Reich and Bill Gates, for example.)  Those currently in political office, however, are quick to express outrage and indignation at these "death panel" accusations.  And their protestations sound almost reasonable, as long as we envision the end-of-life budget bureaucracy as a cabal of Mengele-like demons, chuckling coldly as they crunch the numbers on this week's list of disposables.

In truth, the death panel is less an embodied reality than an underlying argument: government-funded health care must cut costs; inordinately high costs are incurred in treating patients nearing the end of life; therefore, such patients must be hurried along somehow, in order to save money.  This argument, a tad too brutal for modern sentiments, requires a corresponding rationalization.  Necessity is the mother of invention, however.  Thus, the need created by the economics of socialized medicine has given rise to the invention of an appropriate, and appropriately Orwellian, rationalization, by way of the new specialty, "end-of-life care."

Modern "hospice care" was founded in Britain during the 1960s by Dame Cicely Mary Saunders.  "Ideally," Saunders said, "the doctor should remain the center of a team who work together to relieve where they cannot heal."  (Leave aside, for the moment, the loaded words "cannot" and "relieve" in that statement.)  Central to the founding idea, typical of British medicine, was that this service should be "free" to everyone -- all well and good, as long as Dame Saunders' project was being funded primarily through private donations.

From this seemingly noble, innocent origin -- symptom relief for the dying -- hospice care developed into "palliative care," a name invented in 1973 by Canadian Balfour Mount.  Alongside this evolution, often at odds with it, arose an increasingly bold faction of "death with dignity" and euthanasia advocates. 

Gradually, the new specialization was swept up in the fiscal realities of government-funded health care, until the bureaucratic number-crunchers, with support from the new academic cottage industry called "bioethics," contrived to turn palliative care into a primary mechanism of cost-reduction in socialized health care -- while providing sufficient rationalization to convince decent humans to perform this function in good conscience.  Palliative care today provides moral and political cover for those who are not prepared to promote active euthanasia, but who nevertheless feel that it can be objectively determined at what point a person has run out of reasons to live (aka social value) and can therefore be hustled out "with dignity" -- i.e., efficiently.  In short, palliative care becomes a de facto death panel.

Predictably, the most "advanced" palliative care programs exist in nations with the most advanced socialized health care systems, the exceptions being those less sentimental socialist nations in which more aggressive forms of "palliation" are practiced openly.  Among developed nations, a recent report on palliative care singled out three countries for criticism as having "inadequately" developed programs: America and Singapore, which have the most market-related (i.e., patient-driven) health care systems, and Japan, which has the world's longest life expectancy.  Go figure.

How does this sentimentalized cost-cutting mechanism work?  I offer, as a case study, the example of an elderly relative of mine, who died in a Canadian Catholic hospital several years ago.  As it happens, her hospital was a few blocks from my home, so I was privileged to be with her several hours a day during her final weeks, and I can therefore recount the nature of her care very specifically.  (Any honest observer who has lived in a socialized health care system has seen many variations of this case, but let's keep it simple.)

This patient was an 85-year-old widow suffering from kidney failure, along with other chronic problems.  She was mobile, and mentally sound.  One day, while she was still undergoing active treatment, she was paid a visit by a pleasant and professional lady dressed in a Hillary-style pantsuit.  This was the palliative care doctor.  She seemed very keen to have the patient's relatives present at this meeting, and she gave every indication of wanting to help the entire family through the coming days.

Her message, delivered very carefully and deliberately, was twofold: first, to the patient, she politely conveyed that in order to receive the necessary care, returning home ("to die" is the unspoken completion of that phrase) was not an option.  Pain relief, alleviation of distress, and so on were available only if the patient remained at the hospital.

Secondly, and with the finesse of a surgeon, the doctor reassured the family that she wished to guarantee that the patient was in control of her own pain-control regimen until the last.  This, she explained, required that the family accept that, henceforth, all decisions must be made by the patient in conjunction with the palliative care doctor.  This exclusion of the family from the decision-making process was explained with the tenderest reasoning.  Because we loved the patient, and did not wish to lose her, we had a vested interest in keeping her alive and conscious at all costs.  But this might cause us to act against the best interests of the suffering patient.  Thus, in order to spare her unnecessary pain, we must be willing to give up our self-interested desire to have a say in her care.  That's right: Dylan Thomas' plea to his father to "Rage, rage against the dying of the light" is now dismissed by right-thinking liberalism as the cry of petty self-interest.

Subsequently, the patient was moved across the hall to a palliative care room, where her "end-of-life care" began in earnest.  Several times each day, nurses came in to ask her whether she was in pain.  Each time, she said "no," and each time the nurses tried to persuade her to avail herself of the powerful medication the doctor had put on standing order for her -- even though she was experiencing no pain.  It was obvious that the nurses were under instructions to get the patient onto an aggressive pain-relief regimen as quickly as possible, regardless of need.  A patient on increasing doses of such medication is quicker to lose mental focus and the will to eat, both of which results are triggers for taking the "palliative" measures to the next level. 

The patient, who happened to have been a nurse herself, at this very hospital, understood the game all too well, and she requested the precise identity and purpose of every pill she was given.  The nurses actually managed to coax her into submitting to a dose of the unwanted pain medication on a couple of occasions when no family members were present.  The effects were severe.  As a result, she became increasingly insistent on having someone with her each time a nurse or doctor visited.  In fact, apart from the fear of death, which this woman handled with a courage I can only envy, her main worry in her final days concerned what the nurses were trying to push on her on an hourly basis.

As the days passed into weeks (weeks spent talking with family, trying to solve old problems, and praying -- think of what those weeks would mean to you), it was clear that the professionals were becoming increasingly perturbed about the occupancy of this bed, which would be needed by other "end-of-life" patients soon.  They were also frustrated by the incessant presence in the room of family members -- interested observers throw a wrench in the works.  (The immediately previous occupants of this "end-of-life" room had had few visitors -- and had died quickly, as they were "supposed to.")

When she had taken a sleeping pill, or was feeling particularly weak, the nurses would come in regularly to test her alertness.  As soon as she demonstrated some loss of mental faculties, you see, the palliative care team would, according to the arrangement, take over her "pain relief" directly.

On the patient's final night, my wife and I were with her.  Kidney failure had weakened her terribly, and her mind was slipping.  She frequently faded in and out of contact with her surroundings.  Knowing her wishes, we hoped against hope that somehow the nurses would fail to notice her deterioration, and she would be allowed to complete her journey on her own terms.  Unable to stay focused, she said silly things, in the manner of one half-dreaming. 

We tried to rouse her near the time the nurse was due to arrive with the evening's medication, but we couldn't keep her alert.  The nurse came, and began aggressively testing for signs of confusion.  By some extraordinary act of will, the patient sat upright and answered the nurse's questions correctly, as well as volunteering a detailed description of the dosage of medicine her doctor had permitted her.  As the nurse left, somewhat bemused, it was clear that our beloved patient knew exactly what she had just done -- what her brilliant performance had won her.

Two hours later, on her terms, she died.  She had outwitted the death panel.  Would that everyone could be so lucky.  Would that everyone could be spared the indignity of being herded prematurely into "death with dignity."  Would that everyone could be spared socialized medicine, and its inhuman cost-benefit analysis.

In the report cited above, Tony Nash, a leading palliative care advocate, and author of the international "Quality of Death Index," criticizes U.S. health care this way:

The focus is on curative care, where doctors focus on curing patients at all costs; the U.S. is an extreme example of that.

Not extreme enough, I fear.  The 2012 election is literally a matter of life and death.  In socialized medicine, the death panel comes disguised as a loving embrace.

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