Ev Ehrlich's Everyday Economics

Death Panels, Pro and Con

            I am, like most of you, amazed and appalled by the discussion of Death Panels.  Many of us expect the right wing to lie without compunction (Iraq and 9/11, Vince Foster, Swift Boats, Obama’s birth certificate – you know the list) but are always impressed by what the specific lie will be. 

            The focus on Death Panels confused me for a while on this score, but last Friday I read a column in the Washington Post by Charles Krauthammer, entitled “The Truth About Death Counseling,”  that made me understand the reason for the furor.  As Krauthammer said (and in admirable high literary dudgeon) the “Death Panel” provision might not be a Panel per se, but it is “subtle pressure applied by society through your doctor. And when you include it in a health-care reform whose major objective is to bend the cost curve downward, you have to be a fool or a knave to deny that it's intended to gently point the patient in a certain direction, toward the corner of the sickroom where stands a ghostly figure, scythe in hand, offering release.”

            A ghostly figure, scythe in hand…Death as Willie Horton!  Well, I give Krauthammer credit – he’s hit it right on the nose.  The Death Panel provision is exactly that – it’s a way to get Americans to confront the incredible sums we spend to keep ailing, aged relatives alive once they are already, obviously, and tragically unable to live without technological sustenance.  My old man was 93 when he died – his kidneys were obliterated and his brain was poached in the resulting nitrogen coursing through his blood stream, which reduced him to a keening, thrashing piece of Divine clay (take that, “ghostly figure…”).  When I instructed the doctors to send him to hospice care, they were genuinely relieved, after all,  I could just as easily have told them to keep him going in case he suddenly jumped up and started speaking Latin.  Quite remarkably, the doctor then told me the hospital had better uses for the bed.  But enough about rationing.

            Krauthammer gets it, even if he apparently disagrees – we need to establish a new social norm in America, one that holds that every moment medical technology keeps your cardio-pulmonary system going is not necessarily worthwhile.  And he specifically understands – unless I credit him too much – that the debate over Death Panels and the other features of the health care bill are really about what our society’s norms should be regarding how we think about health-related issues.

            And if President Obama truly wants to be a “transformational” President, he’s probably thinking in those ways as well.  It’s possible – unavoidable – to think about American social progress as being measured by the norms our society develops to replace the old ones.  The 40 hour work week, the extension of suffrage, progress towards civil rights, women’s rights, and gay rights – all were or are matters of what reasonable expectations we, as a people, decided to adopt.  I remember dorks in high school (1965 or so) who argued against the Civil Rights Act because “you can’t legislate morality.”  Leaving aside the layers of paradox and irony embedded in that remark, they were right.  But you could pass a law and confront the populace with reality until they got it which, to a great extent, they did.

            Cigarette smoking was a norm, now it produces a reaction that’s almost totalitarian.  Recycling is taught to our kids as a gospel, cost-benefit analysis be damned.  Every newspaper on the continent uses the term “Ms.”  They’re all about evolving norms.

            Which brings us back to Krauthammer.  Giving doctors incentives to talk to patients about living wills, as he points out, won’t really amount to much, “except for the demented orphan.”  (Jeez!  As someone who’s given to literary excess myself, this guy ought to be my hero!)  But it will force people to consider the question of what constitutes a “reasonable” death, if only because doctors will be paid based on quality measures that include whether their patients have considered it.  And that means challenging, to some inevitable extent, the idea that deciding when to die in the context of a DNR or living will usurps “God’s” authority to determine when our time has come.

              I don’t know if Krauthammer believes this last part.  Much of the God-fearing right wing probably does, although I’d be surprised if Krauthammer, a guy with a tragic medical history, was that foolish.  In a world of medical wonder that has rescued us from a Hobbesianly brutish and short life span, the idea that we die when God or Fate wills it obtains only if God invented angioplasties and dialysis.  Like Krauthammer and many of you, if I lived in the 17^th or 18^th centuries, I’d be dead today a few times over, so God’s will has become much more forgiving in the intervening decades. 

             To many, any compromise on the idea that we live every damn day we can squeeze out until the paddles produce no response (or until Bill Frist reviews the videotape) smacks of eugenics.  And to continue, and here I may be stretching, the idea that death has elements of social norms and that man’s relationship to life is governed by something other than a Divine Absolute quickly flows downhill to assisted suicide or worse, abortion.

That’s what’s going on here, to my thinking.  The right wing knows that if people start to consider whether to have DNRs and living wills, and if they start to form new norms about the end of life and the balance between life and death, they’ll rethink their attitudes towards life and death, much as they rethought their attitudes towards the environment, people of color, the workweek, and any number of other things.  In fact, I could argue that the best steps we could take to fix the health care problem in the U.S. would be precisely that -- to force such a reappraisal about the end of life, and a similar one regarding the individual’s responsibility for their own care. 

The latter is also starting to take root – you see it in local laws about transfats in foods.  (I was pleasantly stunned, when I made my first trips to both the new Yankee Stadium and Citi Field, to find calorie content listed next to every item on the food concession stands.  A knish only has 180 calories!  I’ll have two!)  We are beginning to form a much-needed new norm about obesity and healthy choices.  If we really wanted to kick that one into high gear, we’d tax employer-provided medical care (above some regionally-defined threshold) as ordinary income, if only to force people to think about what coverage is truly worth.  But that might be asking too much, for now.

So Krauthammer’s right – or let’s hope he’s right.  The health care law that emerges from the Congress (as I believe one will, for better or worse) will help society form new norms and expectations about the end of life and, hopefully, about responsibility for one’s own health.  The law will lead them there.  If it does, President Obama may well succeed in truly being “transformational,”  by transforming not just the law, but how people make choices.  Or, as John Wayne so eloquently said, “if you’ve got them by the balls, their hearts and minds will follow.”