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Economist: The politics of death


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The politics of death

Sep 3rd 2009

From The Economist print edition

Americans fear health reform because they fear the Reaper

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Illustration by Peter Schrank

http://www.economist.com/world/unitedstates/displayStory.cfm?story_id=14363134&source=hptextfeature

THE first patient Dr Sherwin Nuland ever treated died horribly in front of him. James McCarty, a 52-year-old construction boss, had eaten too much red meat, smoked too many Camels and suffered a heart attack. Dr Nuland, then but a student, was asked to keep an eye on him while he recuperated. Suddenly, McCarty threw his head back, bellowed out a wordless roar and hit his own chest with balled fists. His face turned purple, his eyes bulged out of his head, he took “an immensely long gurgling breath”—and he died. Since this was half a century ago, Dr Nuland did what the textbooks then recommended. He cut open his patient’s chest and tried, unsuccessfully, to massage his heart back to life with his bare hands. It felt like “a wet, jellylike bag of hyperactive worms”. And it did no good. The “dead McCarty… threw back his head once more [and gave] a dreadful rasping whoop that sounded like the hounds of hell were barking.”

That story is one of several that make up “How We Die”, a book Dr Nuland wrote in 1993, after a lifetime of watching the effects of terminal illness. Because modern life is so clean and orderly, he argued, people expect to die with dignity. But this may be wishful thinking: death can be dirty, ugly and often involves the “disintegration of the dying person’s humanity”. Despite its gloominess, “How We Die” was a huge success, because it addressed with excruciating honesty mankind’s greatest fear.

The current debate about health-care reform is in part a debate about death, which is why it evokes such fear. Some of this fear is absurd. Outside a town-hall meeting in Reston, Virginia, last week, a few buffoons likened Barack Obama to Hitler. But most of the protesters are sane. Mr Obama plans to cover millions of uninsured people, says Brittany Tomaino, a young would-be oncologist. He will have to find the money somewhere. That means cuts to Medicare, the government health plan for the elderly, which covers her 95-year-old grandfather, she reckons. “If he needs care, they’re going to give it to someone younger,” she predicts.

A slim majority of Americans support Obamacare. But that majority is declining, and the passion is mostly on the other side. Pro-lifers, for example, worry that reform will mean taxpayer-funded abortions. Half of all Americans believe this will happen. Democrats point out that the bills in question do not mention abortion. Pro-lifers respond that the language is vague enough to allow bureaucrats to add abortion funding after the bill is passed. They also fret, like Ms Tomaino, that Mr Obama will deny life-saving treatment to Grandpa to save money. This possibility alarms Grandpa, too. Americans over 65 currently receive, through Medicare, fantastically generous health insurance for which they pay only a small fraction of the cost. Only 23% of them think Obamacare will make them better off, while a growing plurality think it will hurt them.

Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?

There are no easy answers. Unfortunately for Mr Obama, some of his academic chums have pondered seriously and publicly about the questions. Cass Sunstein, an adviser, has written extensively about which life-saving rules are most cost-effective. Ezekiel Emanuel, a doctor whose brother is Mr Obama’s chief of staff, wrote a paper for the Lancet, a medical journal, in which he proposed a system for determining who should be first in line for such things as liver transplants or vaccines during an epidemic. Among other factors, he suggested taking age into account, with adolescents and young adults getting priority, because they have fully developed personalities and many years of life ahead. This may be philosophically defensible, but it is political poison—Dr Emanuel even included a graph showing voters above and below the ideal age how much less their lives are worth. Conservative talk radio predictably dubbed him “Dr Death”. Republicans vowed last week to outlaw the rationing of care by age.

Blithe and distrustful

Mr Obama’s supporters say that objections to his reforms are largely based on misunderstanding, fuelled by Republican scaremongering. They have a point. But the Democrats’ bigger problem is that most Americans have pretty good health insurance and no idea how much it costs. Taxpayers foot the bill for the old. Most workers with employer-provided health insurance imagine that their employer is paying for it, when in fact it comes out of their wages. Soaring medical inflation depresses Americans’ standard of living and threatens to bust the budget. The system is riddled with waste. Yet most Americans feel little urge to make it more efficient. When asked if insurance firms should be obliged to pay for expensive treatments that have not been proved more effective than a cheaper alternative, 56% say yes.

Few Americans have a clear idea how Obamacare will affect them—unsurprisingly, since even quite basic details are undecided. The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. Many Americans do not trust the government to do anything much, let alone make decisions about life and death. Small wonder Mr Obama finds the headwind against health reform so blustery.

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"The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. "

That was the keypoint. The 85%'s will eventually lose quality of care, money through taxes and their decision making.

I think everyone agrees reform is needed, but govt control is just stupid.

Walk into the post office or BMV and imagine that for health care.

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"The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. "

That was the keypoint. The 85%'s will eventually lose quality of care, money through taxes and their decision making.

I think everyone agrees reform is needed, but govt control is just stupid.

Walk into the post office or BMV and imagine that for health care.

The 15% would walk into what exactly? A homeless shelter? You know to keep the analogy going

your analogy would make sense if the coverage was supposed to be for 100% of the people instead of 15%... but it's not so it doesn't.

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It's just scary the control the government will have over people's lives. My grandfather was 78 when a doctor messed up a simple colonoscopy procedure and he almost died. He needed surgery and the doctors were hesitant to try because he was too old. But he was a fighter. He had the procedure and everything went well. My grandfather lived for another 12 years. Under obamacare they would have just cut their losses and given up on him.

I am 24 and I have 2 younger siblings. My dad is 59 and I hope he lives as long as my grandfather (his dad) did. He's been healthy his whole life. I'm just hoping that in 8-10 years, if God forbid he has some health problem they will save him and let him live on rather then as obama put it, give him the pain pill and hope for a miracle. I am so scared of this **** getting passed. It's a shame most of america couldn;t see past the empty slogans and buzzwords last november.

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I think your post is demonstrates exactly what we are going to have to talk about and deal with as a country. I find it hard to believe that insurance companies are less likely to cut the cord than the federal government would be. If the insurance company allowed the procedure why wouldn't the fed? Keep in mind that this really wouldn't really apply anyway since apparently your grandpa had insurance, which really isn't the group of people we are talking about.

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You say that gov't control is stupid, but who else is going to lead reform?

The current system is pretty good, but it's unsustainable. That's the main problem. People balk at losing more of their paycheck to rising taxes, but the same thing is happening with health care. Costs will always rise if nothing is done to control it.

There are several key aspects of the current system that are fundamentally unsound. I don't care if gov't fixes them or private sector does, but I highly doubt that companies will take the initiative.

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It's just scary the control the government will have over people's lives. My grandfather was 78 when a doctor messed up a simple colonoscopy procedure and he almost died. He needed surgery and the doctors were hesitant to try because he was too old. But he was a fighter. He had the procedure and everything went well. My grandfather lived for another 12 years. Under obamacare they would have just cut their losses and given up on him.

I am 24 and I have 2 younger siblings. My dad is 59 and I hope he lives as long as my grandfather (his dad) did. He's been healthy his whole life. I'm just hoping that in 8-10 years, if God forbid he has some health problem they will save him and let him live on rather then as obama put it, give him the pain pill and hope for a miracle. I am so scared of this **** getting passed. It's a shame most of america couldn;t see past the empty slogans and buzzwords last november.

It's sad that this kind of thinking is real. Sorry, but the thing about your grandpa being left for dead by a hypothetical health care system is just wrong. Believe it or not, us non-conservatives, some are also doctors and some also have loved ones.

I'm so ashamed that most Americans listen to Hannity and Fox news too much.

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It's just scary the control the government will have over people's lives. My grandfather was 78 when a doctor messed up a simple colonoscopy procedure and he almost died. He needed surgery and the doctors were hesitant to try because he was too old. But he was a fighter. He had the procedure and everything went well. My grandfather lived for another 12 years. Under obamacare they would have just cut their losses and given up on him.

Who was your grandfather's health care provider when he was 78? My guess was that is was the US Government through Medicare. You know, the government run health care program with customor satisfaction rates in the 90s.

How would anything change with the legislation?

You are terrified that government controlled health care would have changed how your Grandfather was treated in the past, when he was most likely treated and survived while under government controlled health care...? I don't get it.

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Americans over 65 currently receive, through Medicare, fantastically generous health insurance for which they pay only a small fraction of the cost. Only 23% of them think Obamacare will make them better off, while a growing plurality think it will hurt them.

But Medicare is funded throughout your working history,NOT just by premiums paid by the elderly.:silly:

We made that choice and now regret it?...Wish to change it?

It's a good piece and I agree for many the fear of death is a major issue in their positions.

There remains the simple fact we have not been able to control costs in medicare/medicaid,while private plans have managed to in the last few yrs.

If we are gonna have reform(or even a public option),we need open ,honest discussion on just how we will control costs...or pay for it.

The house bill lays that off on appointed panels to avoid direct responsibility.

If reform is truly needed(and I think it is) we need to make the arguments in favor openly and in advance...as well as make the tough choices.

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Currently, health care is like an all you can eat buffet: as long as you have coverage, you can receive any treatment* even if it only has a marginal affect on your health. That's not a good way to keep costs down. This is where the whole "death panel" thing gets skewed.

Politicians tend to make things overly dramatic, thousands more cases happen where things are not life threatening and are just mundane. I've had instances where doctors prescribed surgery and I went to get a second opinion and all I needed was some drug. I've had instances where dr recommended an MRI and he had already established that there was nothing structurally wrong with my knee.

I hate to say it, but some doctors just love to pad the bill.

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Walk into the post office or BMV and imagine that for health care.

I must be the only person in the world who has never had a problem at the post office. Or even really at the DMV.

And I do know I had a doctors appointment two weeks ago where I didn't get in until 2 hours after my scheduled appointment time.

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Americans over 65 currently receive, through Medicare, fantastically generous health insurance for which they pay only a small fraction of the cost. Only 23% of them think Obamacare will make them better off, while a growing plurality think it will hurt them.

But Medicare is funded throughout your working history,NOT just by premiums paid by the elderly.:silly:

So is Social Security. You want to argue that it's a good system?

(I'm jerking your chain, a little. I agree with your point.)

There remains the simple fact we have not been able to control costs in medicare/medicaid,while private plans have managed to in the last few yrs.

Well, the way both my parent's private health care plans controlled costs was by dumping them the day they turned 65, and forcing them into Medicare.

If we are gonna have reform(or even a public option),we need open ,honest discussion on just how we will control costs...or pay for it.

Agreed.

The house bill lays that off on appointed panels to avoid direct responsibility.

Also agreed. I've also explained why I think that that's both the correct way to do it, and the only way, in the real world, it will ever be done.

(The analogy I use is the closing of military bases. Congress lacks the political cojones to make those decisions. (Because Congress is too beholden to local special interests.) Only way it was ever going to get done was to create a body which is as non-political as possible (I recognize that it's impossible for anything Federal to ever be completely non-political) and then give Congress a veto power.)

Edit: Observing that I think I've agreed with every major thing you've said. I think we only disagree as to some of the finer "how do we get there" things.

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Who was your grandfather's health care provider when he was 78? My guess was that is was the US Government through Medicare. You know, the government run health care program with customor satisfaction rates in the 90s.

How would anything change with the legislation?

You are terrified that government controlled health care would have changed how your Grandfather was treated in the past, when he was most likely treated and survived while under government controlled health care...? I don't get it.

BUT assuming it was Medicare, you can easily argue that the government probably SHOULD NOT have paid for his care.

Nobody doubts that Medicare is going broke. It CAN NOT afford to continue to cover care in the manner that it has historically based on the monies it bring in.

My problem w/ government medical care is EXACTLY opposite of most other people. I think it does (where it exist) and will continue to do a bad job of saying NO, but SOMEBODY (and normally not people that can vote or are even alive) are going to have to pay.

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The house bill lays that off on appointed panels to avoid direct responsibility.

If reform is truly needed(and I think it is) we need to make the arguments in favor openly and in advance...as well as make the tough choices.

Actually, the panels have no direct authority as I understand them, and as a result will result in no savings according to the CBO study I saw.

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Actually, the panels have no direct authority as I understand them, and as a result will result in no savings according to the CBO study I saw.

Now, the panels I think he's referring to (have to be careful, when discussing this subject, to make sure you're both talking about the same thing) have supposedly been given the task of producing lists if things that Medicare (and, I think, Obamacare) won't pay for.

As somebody explained it to me, the panel will produce a list, and then Congress will be allowed to make an up-or-down vote on the entire list. (But not to amend it.)

Which was what initially made me thing of the Base Closure Commission, because I think that's the way that body functions, too. It was done that way intentionally, specifically so that Congressman Lardbutt wouldn't be allowed to try to save the base in his district.

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I'm also remembering reading about a study that was done, tracking the life expectancy of patients who had received certain types of very popular medical procedures, and comparing their life expectancies against patients whose doctors recommended those procedures, but who chose not to have them.

And in a lot of cases, the people who had, say, angioplasty, didn't live any longer that the people whose doctors recommended angioplasty, but the patient declined.

One result that really stuck in my mind was that people who had heart bypass surgery actually had shorter life expectancy than the people who didn't have it.

Although it was also pointed out that, of the people who were treated for condition X didn't die of condition X, (that the procedure did prevent the thing that they were trying to prevent), they died of something else, instead.

That, for example, of the folks who had heart bypass surgery, but died within 5 years, anyway, very few of them died of heart attacks. In fact, more than half of them died from infections which they got while they were in the hospital.

----------

Should Medicare pay for heart bypass surgery, if the statistics say that the people who receive it don't live any longer than without it?

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Should Medicare pay for heart bypass surgery, if the statistics say that the people who receive it don't live any longer than without it?

That's where statistics and averages fail..every situation is not equal.

How many of those that rejected it had minor vs major blockages(or no other complications)?

Should they pay to intubate granny and provide care or let her die quickly?

Statistics say???:silly:

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Actually, the panels have no direct authority as I understand them, and as a result will result in no savings according to the CBO study I saw.

That would depend both on what recommendations they make and which are accepted in whole.

Larry the base closing thing didn't work out too well either in many cases.

A cowards way out for politicians imo.

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That's where statistics and averages fail..every situation is not equal.

How many of those that rejected it had minor vs major blockages(or no other complications)?

Yeah, it did occur to me to at least question those statistics, because of the possibility that maybe the ones who had the surgery were in significantly worse shape than the ones who didn't. That just because the two groups had the same life expectancy, doesn't mean that if the procedure wasn't done, then they still would have had the same expectancy.

OTOH, if statistics are useless, then how do the people paying the bill make a decision as to whether Procedure X is worth the money?

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That would depend both on what recommendations they make and which are accepted in whole.

Larry the base closing thing didn't work out too well either in many cases.

A cowards way out for politicians imo.

Agreed.

OTOH, if your choices are

a) A cowards way out

B)

Wait for Congress to evolve a spine, then engage in honest, open, debate, and arrive at a decision which is best for both the country and for individuals, without political grandstanding, mock outrage, special interest influence, and the chance to lie about what the other Party is doing.

Which one to you think is more likely to result in at least a partial solution, some time in the next century?

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Yeah, it did occur to me to at least question those statistics, because of the possibility that maybe the ones who had the surgery were in significantly worse shape than the ones who didn't. That just because the two groups had the same life expectancy, doesn't mean that if the procedure wasn't done, then they still would have had the same expectancy.

OTOH, if statistics are useless, then how do the people paying the bill make a decision as to whether Procedure X is worth the money?

There is also the factor of quality of life to be factored in.

Are those rejecting bypass a burden vs those getting them productive?

Is existing the same value as living productively?

A bit of a sticky wicket:silly:

Right now in medicare/medicaid we simply defer to the Dr and patient in most all cases...which ain't working out financially.

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Agreed.

OTOH, if your choices are

a) A cowards way out

B)

Wait for Congress to evolve a spine, then engage in honest, open, debate, and arrive at a decision which is best for both the country and for individuals, without political grandstanding, mock outrage, special interest influence, and the chance to lie about what the other Party is doing.

Which one to you think is more likely to result in at least a partial solution, some time in the next century?

:hysterical:

I support reform and review panels limited to govt funded ins.

Let them get the bugs out there before adding a public mandated mess to it.

Ease the rules baring interstate ins competition and limit the free care we mandate in the interim.

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Right now in medicare/medicaid we simply defer to the Dr and patient in most all cases...which ain't working out financially.

Agreed. The only alternative is "we'll pay for whatever the Doctor recommends".

Which does have some merit. After all, he's the "man on the ground" who actually knows the patient's circumstances, and is trained in what the options are.

But do you really expect the Doctor to not, say, send somebody in for a bypass, if there's a slight chance that it might work?

(Although that's why I do think that, if we go with the "panel", that it should be partially, if not entirely, restricted to Doctors. I think I'd go so far as to say "Doctors who have never held elective office".)

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