With multiple proposed health care bills, the largest having over 1000 pages, and a lot of heat being generated on both sides of the debate, there are many misconceptions and odd beliefs about what national health care will eventually look like. Both sides in the debate have made assumptions about the legislation which may not entirely be borne out by reality and there is a great deal of confusion and acrimony as a result.
One example of this is the focus of some health care reform opponents on the issue of “death panels.” There is a widespread belief, especially among concerned seniors, that part of the health care reform is the establishment of some sort of severe rationing program of care for the elderly or the chronically ill which will include panels of doctors who will review these cases and decide which old people and long-term care patients are worth saving and which ones require too much care and will essentially be put down like stray dogs.
The fact is that there are no specific provisions at all for death panels or any kind of end of life review or forced euthanasia in any of the health care proposals. Congressmen are not entirely stupid. If such a thing were actually in a bill their staff (who actually read the bills) would tell them about it, they would realize that supporting it would be political suicide and they would take it out of the legislation.
So where does belief in these death panels come from?
Two elements in the main health care bill (HR3200) contribute to this belief. One is the section on “end of life” counseling, which is part of a large section on making various psychiatric services more widely available. But this counseling is only counseling — providing psychiatric support for the elderly — it doesn’t include any provisions for ending peoples lives, just for helping them deal with the inevitable. The other element is the extensive implementation in the bill of Comparative Effectiveness Research, which is correctly assessed by many as a form of health care rationing using boards of experts to evaluate what is cost effective and what is not. Theoretically, these CER boards could include one which rations care for the elderly in ways which might amount to deciding who is worth keeping alive and who it would save money to let die, but nothing like that is explicitly spelled out in the bill.
Another major factor contributing to the hysteria about possible death panels is concern about the role which will be played in national health care by Dr. Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel, who has been made a White House health care policy adviser. The problem with Emanuel and his role in health care policy is that he is a bioethicist who has expressed beliefs which many interpret as endorsing eugenics and euthanasia in a prominent article in 1996 and another article on the subject which appeared in The Lancet this year. In his recent article, Emanuel’s basic position is that determining allocation of care based on ability to pay or quality of insurance coverage is unfair and that decisions on health care rationing should be made by boards of government appointed experts. While this is clearly a socialist approach to health care it’s not terribly radical, since actuaries are already making those decisions for insurance companies, but it does imply the creation of boards or panels to decide who gets treatment or doesn’t which could mean life or death for many, especially the elderly. His 1996 article is a bit more controversial, suggesting that there is no real social value in providing life preserving care to patients who are comatose or in extreme states of dementia or whose quality of life is extremely low.
The issue is further complicated by the fact that Dr. John Holdren, President Obama’s Science Czar, was involved in the population boom hysteria of the 1970s and co-authored an article with Dr. Paul Ehrlich in 1969 on population control, as well as writing another article in a 1977 textbook suggesting that the only way to deal with the growth of population would be measures like euthanasia and mass sterilization. Since then, Ehrlich’s thesis in The Population Bomb has been conclusively debunked and like other responsible scientists who once advocated radical population control, Holdren no longer supports it.
So the belief that national health care reform will lead to death panels or something like them for the elderly and infirm derives from the assumption that once the general concept of Comparative Effectiveness Research is established, people like Dr. Emanuel and Dr. Holdren will be in the position of determining the specifics of how CER will be implemented, and based on Dr. Emanuel’s past writings there are many who suspect that he will implement boards to review all aspects of care for efficiency, based on providing the most care to those who can benefit from it the most, which will leave many who require end of life or long term care way down the list of priorities, essentially condemning them to death by government panel.
On the one hand there is nothing at all in the proposed legislation which spells out this idea of death panels, eugenics or euthanasia. But on the other hand, the scenario on which the concern is based is entirely logical. Based on examples from other countries with national health care, the process of reviewing cases for efficiency and allocating resources — healthcare rationing — is an integral part of any such system, just as it is in our current private insurance system. So there’s reason to be concerned if the person or people in charge of such programs have a record of advocating writing off certain groups as not worth keeping alive, and while Holdren might not play much of a role in such policy, Emanuel very likely would.
Both sides have good arguments here, but there is also a good measure of hysteria. Dr. Emanuel’s articles are not as radical as many have made them out to be and he doesn’t really endorse organized eugenics, and Dr. Holdren’s position doesn’t really involve him in health care policy. Nonetheless, their association with the administration at a time when health care reform is being considered may look very scary to those who think every fetus is sacred and who wanted to keep Terry Schiavo alive as a vegetable for all eternity.
Yet all Emanuel really advocates is rationing health care, so once you accept that premise nothing he has proposed is particularly radical. What the real meat of this question comes down to is whether you prefer to have your health care decisions made by the state based on ethical priorities or by your choice of insurance plans where the limitations would be based on willingness or ability to pay. That’s a reasonable basis for disagreement, but reducing it to an argument over death panels and eugenics is mostly hysteria.