"End of Life" Care and Health Care Reform

As I have mentioned in previous postings, the potential issue of de facto government involvement in" end of life care" is, by virtue of my temporal proximity to such involvement, a matter of great personal interest. After reading last week's edition of the New England Journal of Medicine, I think that it's time for everyone to devote a little more attention to this topic.

Among the bipartisan antics of last summer's presidential election was the so-called "death panel" issue that was raised by the most unqualified candidate for any office in elected government, Sarah Palin. For those whose short-term memory is worse than mine, here is a brief recap.

According to Palin, a "death panel" would be an administrative body that would determine which patients would live or die once health care becomes a rationed commodity. The "justification" for this claim was a provision buried inside a lengthy House appropriations bill that would allow Medicare to pay for an end-of-life, or "terminal illness consultation," by a group composed of physicians, social workers, clergy, and patient's rights advocates once every 5 years.

And just when I was ready to write that issue off as a rare case of the conservatives telling a bigger lie than the liberals, I read Benjamin Corn's "Ending End-of-Life Phobia - A Prescription for Enlightened Health Care Reform" (Note 1).

In this short editorial Dr. Corn notes that "... leaders have been remarkably reticent with respect to one aspect of the health care system:end-of-life care. Given that patients with terminal illness require a disproportionate concentration of expenditures, the silence is deafening."

What Dr. Corn refers to in the "...terminal illness require a disproportionate concentration of expenditures..." statement is the long-known fact that, in general, most health care spending occurs during the last six months of the patient's life. This should not be all that surprising since it is also a known fact that, again in general, people tend to be sicker in the six months prior to their death than at any other time! Within these observations lie ethical and legal minefields: at what point does de facto rationing occur and can such rationing be reconciled with provisions of existing laws protecting the rights of the elderly and those with physical disabilities? People always seem to forget that children can have terminal illnesses as well. Would you want you child's or grandchild's life entrusted to some bureaucrat?

The logic behind Dr. Corn's, and congress', logic is straightforward but flawed: since most spending occurs in the last six months of life, if we limit spending during that period we can save money and then use those savings to pay for expanded care.

Correct me if I'm wrong, but the concept of saving money is predicated on the fact that available money is not to be spent. Otherwise it is simply redistributed and, in many cases, the supposed 'savings" are at best illusionary. As an example, suppose that you want to buy a new car. You, of course, have a number of options. If you want to buy an $80,000 Mercedes, but instead buy a $25,000 Ford, you have not saved $55,000! You have merely reduced the extent to which you have gone into debt.

Dr. Corn is a Radiation Oncologist (a doctor who treats cancer with radiation) at the Institute of Radiotherapy, Tel Aviv Medical Center, Israel. To be sure, he holds a faculty appointment at Jefferson Medical School in Philadelphia, but the latter position is only a "courtesy" appointment necessitated by a legal requirement that researchers receiving any funding from the United States National Institutes of Health, or one of its member institutes, must be members of the medical staff at an American facility. I will not insult your intelligence by asking you to consider why American tax dollars are being spent on research conducted in Israel.

In summation, I invite you to read the closing paragraph of Dr. Corn's comments (with a few observations by your humble correspondent).

"Concerns over the end of life will never die. (Great choice of words, Dr. Corn, can youspell "l-o-u-s-y" and"p-u-n" too?). But denial of our mortality is no longer an option (we have to admit that everyone is going to die). If we muster the courage to address the last collective phobia of the Western world (if we can sneak it though congress),we may generate ideas for truly comprehensive health care reform and better living" (if some bureaucrat decides to pay for treatments that keep you alive).

I don't know about anyone else, but to me the mere suggestion that a physician from Israel seems to be advocating any form of bureaucratic administration over the "delivery" of health care in the "end of life" period reeks of elitist arrogance, an ignorance of history, and gross hypocrisy. Perhaps Dr. Corn should ask his elderly patients if they can recall the results of Germany's "experiment" with such matters in the 1930s and 1940s.

Notes

1. Benjamin W. Corn. "Ending End-of-Life Phobia - A Prescription for Enlightened Health Care Reform" New England Journal of Medicine, Online Edition, December 16, 2009.