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Medicare and end-of-life medical care

Medicare recently announced that it will pay for end-of-life counseling as a legitimate medical service. This announcement provoked little controversy. Several groups, including the National Right to Life Committee, expressed concern that such counseling could coerce elderly individuals to terminate medical treatment they want. However, Medicare’s statement was largely treated as uncontroversial—indeed, almost routine in nature.

In contrast, it was only six years ago that claims about “death panels” were central to the debate about Obamacare.

What has happened between now and then? I suggest that, over the last half decade, Americans have become better informed about the realities of end-of-life medical care. Much such care is expensive and futile. Families often wish in retrospect that they had not put their loved one through uncomfortable and unsuccessful end-of-life treatment. A significant chunk of the public debt we are leaving our children and grandchildren is attributable to unsuccessful end-of-life medical treatment. Such treatment, often involving expensive technology, is a major reason that health care costs are higher in the United States than in other developed nations.

In important respects, the issue is not new. A century ago, in one of his celebrated decisions on New York’s Court of Appeals, Schloendorff v. The Society of New York Hospital, Benjamin N. Cardozo affirmed the fundamental right of individuals to decline medical treatment they do not want:

Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and a surgeon who performs an operation without his patient’s consent commits an assault, for which he is liable in damages.

In other respects, however, our current situation is, for two reasons, unprecedented: The size of the aging baby boom cohort and the expensive, high-tech way we die today. The net result of these two forces is that Medicare and other US retiree medical programs today spend enormous sums on unsuccessful end-of-life medical care and confront the prospects of even more such expense in the future.

Over the last half decade, Americans have become better informed about the realities of end-of-life medical care.

Since Cardozo’s time, the law has developed a variety of instruments designed to implement individuals’ desires about end-of-life medical care. Such instruments are variously denoted as health care instructions and living wills, and have become ubiquitous.

However, for two reasons, declining end-of-life medical treatment remains a problematic task for elderly individuals and their families. First, many physicians are often reluctant to say that there is no hope for a dying patient. Cynics suggest that this reluctance stems from the fee-for-service method of paying doctors. Under that method, doctors aren’t paid when they don’t perform services. I suggest that there is a deeper phenomenon: Physicians, like all of us, believe in what they do and have a natural reluctance to admit that their healing skills have been unsuccessful.

A second problem is that, even when the argument for terminating treatment is intellectually compelling, it is emotional wrenching to withhold such treatment. As a result, much expensive, end-of-life treatment proceeds because that is emotionally easier than withholding treatment. Only in retrospect does the family recognize that they futilely put their beloved through an unnecessarily unpleasant death.

But beyond these considerations is a harsher truth. Even if families and physicians sincerely want to continue treatment, it is often not in society’s interest to proceed with expensive treatment with little chance of success. Rarely are the patient and his family spending their own resources on such treatment. More typically, the taxpayer or other health insurance premium payers are financing this care.

Medicare is right to encourage discussion among patients and their doctors about end-of-life care. Opponents of Medicare’s decision are right to caution that counseling should not become coercion. However, at the end of the day, the United States needs to control the costs of end-of-life medical care. We cannot afford unlimited end-of-life medical care. Not controlling such care will saddle our children and grandchildren with the high costs of much futile end-of-life care for the aging baby boom cohort. Our children and grandchildren deserve better.

Image Credit: “Senior Citizen with Doctor” by Andy De. CC BY NC 2.0 via Flickr.

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