The dumbest controversy of Obamacare, by far, was when Sarah Palin took an anodyne provision directing Medicare to cover end-of-life care consultations and branded it a "death panel." Senator Johnny Isakson, a Georgia Republican who had backed the idea, was unsparing. "How someone could take an end-of-life directive or a living will as that is nuts," he said. PolitiFact gave Palin its coveted "Lie of the Year" award.
But Palin won. The provision was deleted from the bill. And politicians learned to fear any discussion of end-of-life care, even though roughly 30 percent of Medicare's spending comes in the last six months of a patient's life.
And that's been the sorry state of Washington's conversation over end-of-life care. Until now.
In New Hampshire on Friday, Jeb Bush made a startlingly sensible proposal. "I think if we’re going to mandate anything from government, it might be that if you’re going to take Medicare, you also sign up for an advance directive," the New York Times reports Bush saying.
This goes much further than the provision in Obamacare. All that did was allow Medicare to pay for "voluntary advance care planning." Bush appears to be suggesting something much more radical, and much more sensible: that Medicare mandates an advance directive as a condition of receiving insurance.
This shouldn't scare anyone. An advance directive can say that the patient wants all measures used to prolong her life, or it can say that the patient wants nothing done. An advance directive doesn't tell you what to choose; it simply forces you to make a choice.
And people should be forced to make a choice. Because if they don't, then terrible things can happen to them at a point when they're no longer mentally or physically capable of choosing.
"End-of-life care" is such a clean euphemism. But CPR cracks the ribs of 92-year-olds with dementia. Brutal surgeries are performed that will leave patients with a few more months of life, at best. There are fates that are worse than death. As one doctor wrote:
Almost all medical professionals have seen what we call "futile care" being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, "Promise me if you find me like this that you’ll kill me." They mean it. Some medical personnel wear medallions stamped "NO CODE" to tell physicians not to perform CPR on them. I have even seen it as a tattoo.
And then there's the awful suffering of the patient's family when they are forced to make life-or-death decisions for a loved one who never made clear the circumstances under which he wanted to live or die.
It's the latter kind of pain that is motivating Bush: he frames his belief in advance directives as the result of his experience trying to help Terry Schiavo's parents keep her alive, even when her husband said that she had never wanted to persist in a vegetative state.
But whatever the motivation for Bush's idea, it's a good one, and it hopefully heralds a presidential race in which the candidates will be willing to talk about end-of-life care like adults.