Section 1233. . . addresses compassionate goals in disconcerting proximity to fiscal ones. Supporters protest that they’re just trying to facilitate choice — even if patients opt for expensive life-prolonging care. I think they protest too much: If it’s all about obviating suffering, emotional or physical, what’s it doing in a measure to “bend the curve” on health-care costs?
Though not mandatory, as some on the right have claimed, the consultations envisioned in Section 1233 aren’t quite “purely voluntary,” as Rep. Sander M. Levin (D-Mich.) asserts. To me, “purely voluntary” means “not unless the patient requests one.” Section 1233, however, lets doctors initiate the chat and gives them an incentive — money — to do so. Indeed, that’s an incentive to insist.
Patients may refuse without penalty, but many will bow to white-coated authority. Once they’re in the meeting, the bill does permit “formulation” of a plug-pulling order right then and there. So when Rep. Earl Blumenauer (D-Ore.) denies that Section 1233 would “place senior citizens in situations where they feel pressured to sign end-of-life directives that they would not otherwise sign,” I don’t think he’s being realistic.
What’s more, 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).
Admittedly, this script is vague and possibly unenforceable. What are “key questions”? Who belongs on “a list” of helpful “resources”? The Roman Catholic Church? Jack Kevorkian?
Ideally, the delicate decisions about how to manage life’s end would be made in a setting that is neutral in both appearance and fact. Yes, it’s good to have a doctor’s perspective. But Section 1233 goes beyond facilitating doctor input to preferring it. Indeed, the measure would have an interested party — the government — recruit doctors to sell the elderly on living wills, hospice care and their associated providers, professions and organizations. You don’t have to be a right-wing wacko to question that approach.
As it happens, I have a living will and a durable power of attorney for health care. I’m glad I do. I drew them up based on publicly available medical information, in consultation with my family and a lawyer. No authority figure got paid by federal bean-counters to influence me. I have a hunch I’m not the only one who would rather do it that way.
Notice that the issue is not the intent but the effect.
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