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Clarity for End-of-Life Planning

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By Kathleen Parker
Wednesday, August 12, 2009

Sarah Palin was right, the second time.

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We do need to turn down the rhetorical heat lest we miss important issues in the proposed House health-care bill.

Unfortunately, Palin's more thoughtful comments followed a made-for-the-tabloids Facebook post suggesting that under President Obama's health-care reform, a "death panel" would kill her elderly parents and her Down syndrome baby.

Once upon a time, radical reformers could only dream of such helpful enemies. Now that the world is chasing hyperbole, we indeed risk overlooking troublesome language in the end-of-life section of the House health bill, a.k.a. Section 1233 of H.R. 3200.

For purposes of civil discourse, let's assume that no one wants to kill off old people. Just as airline pilots have a primary interest in safely landing planes, even Nancy Pelosi, Harry Reid and Barack Obama will be elderly someday.

Meanwhile, we all know that America's health-care system is in dire need of repair. We also know, though we're loath to admit, that we can't do all things for all people. Technology that enables us to prolong life far beyond what is natural or desirable also threatens to cripple us financially.

How do mere humans balance the immense powers of "can" against the humbling moral quandary of "should"? This is partly what the bill's end-of-life section aims to address.

Theoretically, rational people can dwell happily on the same page. Wouldn't we all rather make end-of-life provisions voluntarily, while we're still healthy, than burden family members, who would be reluctant (one hopes) to pull the plug on our darling selves?

Of course. In practice, however, the debate is over whether these consultations are conclusively voluntary -- and the bill, to the extent it is comprehensible at all, is vague enough to cause concern.

For instance, the bill makes end-of-life consultations reimbursable under Medicare every five years but allows for more frequent Medicare-reimbursed sessions should a person's condition worsen. These consultations allow for the formulation of "an order regarding life-sustaining treatment."

We can all imagine a situation when we might not want any more life-sustaining treatments -- when death is imminent, for example. But we can also imagine a scenario when, feeble and ill, we might be subtly urged to forgo further life-sustaining treatment out of consideration for others. Given that "actionable medical orders" can be formulated from advance care consultations, the danger is that life-sustaining care would be precluded based on a check-mark on a document you signed five years earlier.

It would be nice to think that everything goes as patients intend, but we can safely assume that when human error collides with bureaucratic efficiency, nightmarish enforcement scenarios could ensue. Likelihoods morph into certainties when, as this bill sets out, primary-care physicians aren't necessarily involved in the consultations. As proposed, a variety of health-care practitioners would do.


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