Burke Balch is the director of the Robert Powell Center for Medical Ethics at the National Right to Life Committee.
Beginning in January, the taxpayer-funded Medicare program will pay health-care professionals to counsel the elderly as they choose to pursue or reject life-preserving medical treatment.
Sadly, most health-care professionals are unlikely to act as neutral assistants. Cost pressures, combined with an increasingly pervasive ideological commitment to avoiding “poor quality of life,” will result in the subtle — or not-so-subtle — “nudging” of those who are most vulnerable to accept premature death.
Today, the universal assumption seems to be that people should be getting less rather than more lifesaving care. The term “end-of-life care” evokes the image of inevitable and imminent death, even with treatment. Yet “terminal illness” is often interpreted to include those who will die soon only if they don’t get lifesaving care. Rejection of treatment is being urged upon those who could live indefinitely but whose disabling conditions can’t be fully “cured.”
[Other perspectives: It’s time to talk honestly about dying]
In the American Bar Association’s worksheet “Are Some Conditions Worse Than Death?,” created to help individuals make those decisions, questions and circumstances are framed negatively for maximum effect. “What if You … No longer can recognize or interact with family or friends; No longer can think or talk clearly; … No longer can walk but get around in a wheelchair; No longer can get outside and must spend all day at home; … Are on a breathing machine to keep you alive; Need someone to take care of you 24 hours a day; No longer can control your bladder; No longer can control your bowels; Live in a nursing home permanently.”
Notice that what is characterized as a potentially unacceptable life may be as minimal as one walking around with a portable oxygen tank, using a wheelchair or needing to use protective underwear.
The motivation for this perspective is out in the open: limiting the amount we spend. “Dying in America,” a report from the Institute of Medicine, claims that because most advance planning participants choose to maximize independence or quality of life over living longer, advance care planning can potentially save health-care costs.
And what makes this planning so effective in suppressing health-care spending? Again, framing is key. A health policy journal article entitled “Decision aids: when ‘nudging’ patients to make a particular choice is more ethical than balanced, nondirective content” gives this advice on how to get patients with prostate cancer to reject costly surgery: “If incontinence and impotence are presented as plainly stated — that is, with no detailed description of these risks — men with early-stage prostate cancer may be swayed toward the option of surgery. If instead those possible effects of surgery are presented vividly via personal stories, men may be swayed away from the surgery option.”
Insurance companies are paying to develop such techniques for use on their own beneficiaries. After the Center for Palliative Care was hired by Aetna to encourage and assist patients in completing advance directives, the Center proudly reported that its programs had saved the insurer more than $12,000 per member.
We are constantly reminded that almost 25 percent of Medicare spending takes place in the final year of life, implying that most of that money is wasted on the inevitably dying terminally ill.
However, experts have noted that “the cost of dying” is a misleading characterization. Most of this spending is not in anticipation of death, but to cope with negative manifestations of disease. To significantly reduce those outlays would require slashing health care for large numbers of severely ill people not known to be dying — many of whom might in fact survive for years if their treatments are successful.
What is especially troubling is that in the rush to limit health-care spending, we are acting as though poor quality of life is inevitable. Instead of putting resources into health care and other measures to improve patients’ conditions, we are promoting death as the preferred medical management option. But when you put a price on human life, the price goes down — over time, the circumstances in which life is considered too intolerable to be worth saving gradually expand to include those of lesser and lesser severity.
Those most often deemed to have a “poor quality of life” are disproportionately found among people of color, the poor, the disabled and those of advanced age. The most vulnerable among us have good reason to fear calculations that make it easier to say: “Your lives aren’t worth saving — stop being a burden and die already!”
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