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More on “Death Panels:” Are Doctors Working for You, Themselves, or Barack Obama?

August 17, 2009
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It seems to me that the debate around end of life counseling paid for by the government comes down to what we think of doctors and what makes them practice medicine.  Republicans are using phrases like “the government will pull the plug on grandma.”  In reality, this bill allows grandma to determine, with her doctor’s advise, when her plug is pulled while she can still make these decisions.  The only role government has here is paying the bill for the conversation.

Yesterday, on CNN, James Carville and Mary Matalin debated this issue.  Matalin actually gives what seems like an honest description of end of life counseling at first, but then her logic goes completely out the window.  Then, of course, Matalin goes completely off the rails and starts throwing out scary words like “rationing,” which has nothing to do with paying doctors to voluntarily consult with patients on their end of life care options.

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Matalin is pretty honest at first.  Yes, this legislation would pay for voluntary end of life counseling.  This means doctors will be able to be paid by Medicare for this type of consulting.  Let’s go along with Matalin’s description that this is primarily a cost cutting bill.  That means the legislators believe this will ultimately save money as more people who may not want every measure taken to keep them alive will be counseled on their options (i.e. a living will, or having a do not resuscitate order in place).

So here is the really simply outline of the problem and what this bill does:

Assumption: there are many people facing the end of life who are not aware of all of their options for treatment.  The patient can have doctors do everything in their power to keep him alive as long as possible, or his doctor can simply “let nature run its course” and not take measures to extend life by hours, days or weeks (at presumably a very low quality of life).  Or, the patient can dictate some course between these two extremes.

Background: If a patient has not planned in advance with their doctor, his doctor will have to take certain measures to extend life even if he does not want this.  Unfortunately, because patients can often not communicate in these situations, the decision is left to doctors and the family without regard for what the patient wants.  Further, this default option (of doing more to extend life) costs massively more than limited steps to make the patient comfortable in their last hours.

Solution: In order to make patients aware of their options before his health has deteriorated to a point where they can’t communicate or make effective decisions, a doctor advises them on all of their decisions.  This is bound to save money if only ONE person chooses a do-not-resuscitate order, because the default option is to spend more and extend life.  No one knows for sure how much this will save because no one knows what individual preference will be for end of life care (though I’m sure there is some data to ball park this number).

And here is where Matalin’s logic completely breaks down.  In my opinion, doctors can be one of three things (or maybe a little of two):

  • Patient-Serving, where doctors exist solely to serve exactly what the patients want.  More procedures?  You want it, you got it.  Ineffective procedures?  You want it, you got it.
  • Self-Serving, where doctors only want more money and time to see more patients (and bill more).  You want another procedure?  Medicare will pay for that, so sure!  You want to put off getting proper care at the proper time and end up in the emergency room rather than the doctors office?  Sure, reimbursements for the hospital when you’re in worse shape will make me more.  Cha-ching!
  • Government-Serving, where doctors do not think of patients health or their own wallets, but simply the national debt and how to ensure that the US doesn’t spend too much on health care.

Matalin assumes that doctors are “government-serving” and will  push patients towards less care simply because legislators included this in a bill to cut costs.  Here’s my problem with her logic.  Obviously doctors don’t only serve themselves, their patients or their wallets.  But in this case, there is no incentive for a doctor to push a patient into less end of life care if they don’t want it.  If a patient wants more care to sustain life, then doctors are both serving the patient and themselves because the patient gets what they want and the hospital gets paid more for performing more procedures at end of life.  Does Matalin really think that doctors are so motivated by the government’s desire to save costs that they’ll make a decision against both their own and their patient’s interests?

In reality, most doctors really just want the best for their patients, and allowing them to consult on end of life options isn’t going to drive them to push one option over the other simply because the government is looking to cut costs.

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