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Saturday, August 8, 2009

An Inconvenient Truth About The "Death Panel"

Sarah Palin has kicked off (another) firestorm of criticism because of the statement she released on her Facebook page:
The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.
The incoming fire has been withering, as usual. Palin is accused of becoming the "Zombie Queen," certifiably insane, "clinically wrong," and espousing a "gruesome mix of camp and high farce."

These critics, however, didn't take the time to find out to what Palin was referring when she used the term "level of productivity in society" as being the basis for determining access to medical care. If the critics, who hold themselves in the highest of intellectual esteem, had bothered to do something other than react, they would have realized that the approach to health care to which Palin was referring was none other than that espoused by key Obama health care adviser Dr. Ezekial Emanuel (brother of Chief of Staff Rahm Emanuel).

The article in which Dr. Emanuel puts forth his approach is "Principles for Allocation of Scarce Medical Interventions," published on January 31, 2009. A full copy is embedded below. Read it, particularly the section beginning at page 6 of the embed (page 428 in the original) at which Dr. Emanuel sets forth the principles of "The Complete Lives System."

While Emanuel does not use the term "death panel," Palin put that term in quotation marks to signify the concept of medical decisions based on the perceived societal worth of an individual, not literally a "death panel." And in so doing, Palin was true to Dr. Emanuel's concept of a system which

considers prognosis, since its aim is to achieve complete lives. A young person with a poor prognosis has had a few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern the disproportionately large amounts of resources will be directed to young people with poor prognoses. When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable....

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.

Put together the concepts of prognosis and age, and Dr. Emanuel's proposal reasonably could be construed as advocating the withholding of some level of medical treatment (probably not basic care, but likely expensive advanced care) to a baby born with Down Syndrome. You may not like this implication, but it is Dr. Emanuel's implication not Palin's.

The next question is, whether Dr. Emanuel's proposal bears any connection to current Democratic proposals. There is no single Democratic proposal at this point, only a series of proposals and concepts. To that extent, Palin's comments properly are viewed as a warning shot not to move to Dr. Emanuel's concept of health care rationing based on societal worth, rather than a critique of a specific bill ready for vote.

Certainly, no Democrat is proposing a "death panel," or withholding care to the young or infirm. To say such a thing would be political suicide.

But one interesting concept which is central to the concepts being discussed is the creation of a panel of "experts" to make the politically unpopular decisions on allocating health care resources. In a letter to the Senate, Barack Obama expressed support for such a commission:
I am committed to working with the Congress to fully offset the cost of health care reform by reducing Medicare and Medicaid spending by another $200 to $300 billion over the next 10 years, and by enacting appropriate proposals to generate additional revenues. These savings will come not only by adopting new technologies and addressing the vastly different costs of care, but from going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions.

To identify and achieve additional savings, I am also open to your ideas about giving special consideration to the recommendations of the Medicare Payment Advisory Commission (MedPAC), a commission created by a Republican Congress. Under this approach, MedPAC's recommendations on cost reductions would be adopted unless opposed by a joint resolution of the Congress. This is similar to a process that has been used effectively by a commission charged with closing military bases, and could be a valuable tool to help achieve health care reform in a fiscally responsible way.
Will such a commission decide to curtail allocation of resources to those who are not deemed capable of "complete lives" based on prognosis and age, as proposed by Dr. Emanuel? There is no way to tell at this point since we do not have a final Democratic proposal, or know who would be appointed to such a commission.

To exclude the issue of allocating resources away from the elderly and infirm from the debate over "cost cutting," however, ignores the ethical elephant in the room. Let's have the debate, and understand specifically how resources would be reallocated, before any vote on a health care restructuring bill.

And before we create a commission to make such decisions for us, let's consider whether we should outsource these ethical issues or deal with them as part of the political process.

Principles for Allocation of Scarce Medical Interventions

UPDATE: Michael Crowley at TNR's The Plank Blog either did not read this whole post or deliberately chose to misrepresent what I said, in making the following statement (italics mine):
Jacobson doesn't even bother trying to defend the other phrase Palin puts into misleading quotation marks--"level of productivity in society"--which as far as I can tell has no connection to any proposal authored or even imagined by any Democrat currently in a position of power. Presumably that's another concept the currently-unemployed Palin didn't have time to spell out.
Are you kidding me? Almost this entire post is devoted to explaining the context and source of the "level of productivity in society" phrase. Crowley's post was "embarrassingly lame" (literally). And, you can add Chris Bodenner at Andrew Sullivan's blog to the list of people who do not read what they criticise.

Related Posts:
Health Care Ghimmitude
Unaccountable Commission May Run Healthcare
"Put Your Laws All Over My Body"

Earworms Destroying Obamacare
Deception and Tyranny Key To Health Care Reform

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  1. They aren't saying that they are going to withhold care from the infirm, but the premiums and deductibles will make it prohibitively expensive for me to pay for my treatments on a govt plan.

    WHen they say they want equality in health care, they really mean it: Middle class sick people should die too.

  2. I don't trust the Congress to debate the ethical issues surrounding health care with any backbone. Unfortunately, I mistrust a Commission without any congressional oversight even more. That should be the jumping off spot -- how would the Commission operate, what is its composition, how is it composed, what is its mission? I'd like to know what the creature looks like before deciding whether to bring it home from the pound.

  3. Did you actually read the article you posted? First, Mr. Emanuel was one of three authors. Second, that recommendation was made the context of medical ethic principles, not actual policies coming from the White House. That juxtaposition is not only dishonest and disingenuous, but also factually incorrect....(which is redundant..) We know Ms. Palin did not actually read the article. I am surprised that you did not

  4. Dear Dr. Jacobson,

    You are, of course, perfectly correct on all points. I simply question the political utility of your efforts.

    You are certainly enhancing the image of professors, an image somewhat sullied by Obama who reinforces the image of an arrogant lecturer who instructs because "I say so".

    Unfortunately, the current ascendant forces are not interested in a rational debate but rather make outrageous statements in order to divert their opponents into defending themselves. Alinsky: "Make them play by their own rules.

    Please don't misunderstand. I find your writing to be a refreshing breeze in the current odiferous cacaphony. Kindly ignore any implied criticism. I'm just kinda cranky this morning. Must be the gin.


  5. "Certainly, no Democrat is proposing a "death panel," or withholding care to the young or infirm. To say such a thing would be political suicide."

    No need for political suicide; just ram the bill through Congress as quickly as possible while demonizing your opposition, mainly, those concerned about the seriously ill, the old, the infirm, and the disabled. Ideally, no "death panel" is needed at all. Let ACORN and the bureaucrat bean counters hammer the regulations together, and the doctor (probably the nurse practitioner) can get stuck with passing sentence by way of diagnosis.

    Quoting Ezekiel Emanuel from another of his published articles:

    "[S]ervices provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia."

    As he says quite clearly in his article, "Where Civic Republicanism and
    Deliberative Democracy Meet" (available online), this is Emanuel's version of the re-making of social "good."

    It seems that "Thou shalt not kill," and " Honor thy father and thy mother" just don't cut it anymore, never mind "Do unto others."

  6. It is amazing how private-citizen Palin can generate such a huge response to a posting on her Facebook page. Is there any other private citizen whose statement would generate this much controversy? Why do so many people, especially those who have written her off as politically dead, care so much about her views? Is that she touched a raw nerve in the topic of government and health care? I do not have the answers, just the questions.

  7. Dear Survivor,

    Let me take a shot at that.

    The left is running scared. They have never seen anything like the Tea Parties - people who have never gone to a demonstration in their lives taking time off work to peaceably assemble. By the hundreds of thousands in every village and farm. (Homage to Longfellow). They know that most all political demonstrations in the past 60 years have been orchestrated by them. They can't believe they're seeing the real thing.

    Their "townhalls" are no longer Norman Rockwellish campaign stops. They have become unfriendly and surly.

    Why Sarah Palin? Ronald Reagan decimated them just when they thought they were close to coming to power. Palin is Nemesis come to haunt them again.

    Who's a thunk that Ronnie would come back as the hottest chick on the planet?


    P.s., Did you survive the Mojave or the strawberry shortcake?

  8. Sorry, you're wrong - and so is Palin.

    You cannot "reasonably construe" that such would be the case for the simple reason that Emanuel is not writing the bill. There is not one scintilla of evidence that anyone on the Hill has been contemplating either a "death panel" or the denial of service to the handicapped. Palin's outrageous demagoguery is like throwing gasoline on to a fire.

    My point is simple: This bill is going to be so bad, so scary, you don't have to make stuff up to get people to oppose it. All people are doing who talk about death panels and forced euthanasia is giving the other side more credibilty and our side less.

    This seems so self evident I cannot imagine anyone who would willingly give the other side the advantage like that. But that's what Palin did - and people who cheer her on really haven't much of a clue.

    Rick Moran

  9. We are now faced with a situation wherein we must, as Americans, choose between the "common good" and the good of our own loved ones.

    That being said... I think we can safely assume that, no matter how well researched and reasoned the argument for the former may be .... the vast majority of Americans will choose the latter.

    I am not going to say who is "right" or "wrong" in this matter. Because there is really no sane and practical way of deciding. But... I will say this: 90% or more of the people on the street will stand with Sarah Palin in this argument.

    And it will be a sliver of public health academicians that will understand and stand with stand with Dr. Emanuel.

  10. @Elvenstar522 - I think I laid things out correctly in my post. Emanuel may not be writing the bill, but the concept of a panel of experts which will decide reallocation of limited resources is a central theme in Democratic thinking. Only time will tell whether that concept makes its way into legislation, and if not, where hundreds of billions of dollars of costs cut will be made. Raising the issue now is not making things up, it is addressing a cost cutting mechanism the Democrats themselves have suggested.

  11. "All people are doing who talk about death panels and forced euthanasia is..."

    Who is talking about forced euthanasia? Palin was very specifically addressing concerns about denial of care.

    Do I detect the odor of demagoguery?

    Although, given that many dementia sufferers are otherwise physically fit (if often elderly) I'm not sure what else could be done with them once they are in need of care...

  12. This issue is a total red-herring manufactured by the right wing to break Obama. The part of the bill in question was inserted by a republican. It is also already common practice in the health insurance industry and is where most denial of service judgments come from. In the end, we are wasting many millions of dollars on a system which survives on unnecessary and clinically false procedures which make a lot of pharmaceutical reps a lot of money. Cost controls are designed to be just that... cost controls, which adhere to a basic standard of care philosophy. This issue is one which, when a health reform passes, people will discover was meaningless. In the end, I predict, not one person will die as a result. But right now - thousands die annually as a result of lack of adequate access and "pre-existing conditions." Denial of care is already very real. This philosophy will help solve it.

  13. This is a classic Leftist technique. They define "death panels" to mean some kind of body that can order the active termination of life, so that they can dismiss Palin's position as either dishonesty, demagoguery, or delusion.

    Althouse correctly identified that isn't what Palin means. If health care financing is totally controlled by government, then whatever agency is given the power to exercise that control can order healthcare withheld from certain classes of people, resulting in their deaths just as certainly as if it were done by lethal injection or any other execution.

    Do note that she said "death panels", not "execution panels" or "euthanasia panels". Those are straw men erected by those who wish to dismiss her comments.

  14. "To exclude the issue of allocating resources away from the elderly and infirm from the debate over "cost cutting," however, ignores the ethical elephant in the room."

    That's already being done in the name of profit. It's called "health insurance".

    Some of the poor and elderly who are not wealthy in this country have to choose between eating and taking medication.

  15. Funny how the same wingnuts trumpeting this issue had absolutely nothing whatsoever to say about the Texas Futile Care Law, which has caused poor people to be put to death in the Republican paradise.

    You freaks couldn't possibly care less about "life." All you care about is politics.

  16. Ramesh Ponnuru wrote a book about the Democrat party called "The Party of Death." Any of us who has been a Democrat and more importantly a leftist recognizes the essential truth of the phrase. To the Left, humanity is evil. Like Hitler, they desire perfection, which leads to agressively pro-abortion policies, eugenics, euthanasia for the unfit and imperfect, etc. Follow the arguments to their logical conclusions. The Democrats' instincts are nihilistic. Palin nailed them but good and they are squealing. "Death Panel" is one of the most apt phrases in recent years to describe the essence of the logical conclusion of Obamacare. It does not have to be literal to be essential.

    Democrats are The Party of Death.

  17. Thank you for the clarity on this issue. Let me add a little something, if I may. We just bailed out an insurance behemoth AIG to the tune of oh $100 billion or so. Mr. Obama wants to save $200 billion on Medicare. Can none of you left wing or right wing fools see the connection here? When money is put ahead of humanity the economics of scarce resources leads inevitably to tyranny. The war reparations placed upon Germany after WWI lead to the bestial final solution. The logic of bailing out criminal speculators too big to fail leads down that same path. If you are not able to understand this it is because you refuse to look this evil in the eye. Thank you.

  18. As a lawyer you've done a commendable job of spinning the langauge of a published medical ethics policy paper and then linking it to some ...well non-existant legislative language. As a citizen however you've failed the test for informed and honest debate.Not to mention the now tiresome and overworked "incovenient truth". Since we're using overworked headlines how about the "Have You No Decency?" reply published at The New Republic by Harold Pollack. Besides debunking this childish "death panel" silliness, you'll note the link toward the end which points out that Dr. Emanuel also published an ethics paper in which he clearly opposes euthanasia and doctor assisted suicide. Certainly strange ethics positions to take by someone who according to your implications is pro patient murder.

  19. @Liberty - Typical strawman argument. You attribute statements to me I did not make, and then disprove the fictitious statements. Dr. Emanuel's view is quite clear, that in a system of scarce resources, it is necessary to prioritize and he suggests an approach. You may not like what the approach stands for, but it is his approach, not mine.

  20. 'That's already being done in the name of profit. It's called "health insurance". '


    Health insurance is a contract, everything is pre-determined. The limits of what are covered are specified in that contract. Not coincidentally the contract also precisely defines what this level of coverage will cost you. The relationship is direct and consequential.

    If the contract specifies a covered item or procedure then you have legal recourse to ensure the item or procedure will be paid for by your insuror. Anything outside the contract is your own obligation.

    Unlike the government, who will not only tell you how much money you have to pay for 'healthcare' but who will then - and only then - tell you just how little 'coverage' your taxes provide.

  21. Just like every other truly patriotic American, I don't want the government making life or death decisions about my health --- I want to health insurance companies to make those decisions! Because large corporations always have my best interests in mind, while the government is always evil evil evil. That why, when we wanted to put a man on the moon, we didn't depend on a communist government beaurocracy like NASA. In this enlightened age, we need to depend more on private companies for things that the evil government used to do. Companies like Blackwater, Halliburton, KBR, Enron --- these companies always have the welfare of the American citizen at heart, whereas the government is simply a conspiracy to destroy the white race through estate taxes and affirmative action.

    I think I've got the Republican ideology down pat.

  22. Hmmh...I wonder why this great communicator can't state for herself who she is responding too and needs others to do it for her.

    I also wonder why it's OK for insurance companies to make their own decisions resulting in the death of patients, or to decline to insure small companies with employees with expensive conditions (at-will employees BTW hint hint), or to rescind individual policies when the covered gets sick based on technicalities like completely unrelated and minor pre-existing conditions.

    These are all rather arbitrary decisions by anonymous 'death panels'.

    Of course I fully understand why Sarah Palin wouldn't be interested in the uninsured millions who are arbitrarily sentenced to shorter lives.

    Also worth noting that she is not above using her child to score a political point, and an absurd (cynical and delusional) one at that.

  23. @kent rationing by any other name (cost controls?) is still rationing. I would rather have MY doctor being the person determining whether pharmaceuticals or "unnecessary or clinically false procedures" that line the pockets of those evil pharmaceutical companies might benefit me. I trust my doctor to give me the best care possible. I CHOSE my doctor. I definitely haven't chosen any nanny state committee to think for me.

  24. Last year, the BBC (http://news.bbc.co.uk/2/hi/health/7510121.stm)reported that the US has much higher survival rates for breast and prostate cancer than the UK:"The study showed the US had the highest five-year survival rates for breast cancer at 83.9% and prostate cancer at 91.9%...The UK had 69.7% survival for breast cancer ... 51.1% for prostate cancer."

    The UK rates would be even worse were it not for drugs and treatments developed in the US private health care system. As in defense, the US subsidizes the socialists in Europe.

    The British National Health Service has a panel with Orwellian acronym of NICE. The official name is the National Institute for Health and Clinical Excellence.

    Tom Daschle[/url], Obama's original choice for Health Secretary, admired NICE, and he had a lot of influence on the Democrats healthcare plans. As the WSJ's Scott Gottleib wrote last year:"NICE's real mission is to protect the British health-care budget. Since 2000 it has denied patients the ability to use the newest cancer drugs -- by my count, in 226 different indications where American insurers, and Medicare, currently pay, and where the National Comprehensive Cancer Network says there is "high-level evidence" or "uniform consensus" of clinical benefit. Cancer survival rates in the U.K. are substantially lower than in the U.S. and the gap continues to widen."

    The Democrats want to include a Comparative Effectiveness Research Commission (CERC) in their healthcare reform package. It would be the US equivalent of NICE and it would determine what treatments and procedures doctors can use. We have already seen evidence that Medicare and Medicare frequently limit treatment options on the grounds of cost. Full blown Obamacare would institute such bureaucratic controls throughout the US health system. CERC would limit cancer treatments in the same way as the NICE limits cancer treatment in the UK. An overloaded, underfunded Public system would also do what NHS does in Britain; introduce long, deadly delays before patients can be screened, diagnosed and treated. Hundreds of thousands of people who would survive under the current US healthcare system would be condemned to death by the bureaucrats of CERC.

    Take prostate cancer. There are 186,000 new cases per year in the US. In the US, 170,000 of those men would still be alive after 5 years. If we had the NHS system, only 95,000 would survive 5 years. By current US standards, that is 75,000 needless deaths per year. But those are the outcomes to be expected when the CERC goes to work on saving health care costs.

    Palin is right to draw attention to CERC. Calling it a death panel certainly gets people's attention.

  25. @ William: But if Zeke's not writing the bill, the argument is a specious one. (Do we even know for certain that Dr. Emanuel is a Democrat? And would it say anything about Republicans and health care, if it were to turn out he's one of them? -- The answer you're looking for, is no.)

    I disagree that Dr. Emanuel is talking about withholding treatment from anyone, but is instead talking about allocating treatment in acute situations where there's only so much of it to go around, such as transplants (1 liver, 10-15 patients in the area who need one) or overcrowded emergency rooms (How many patients can one ER treat at a time, and how does s/he decide who goes first (a decision that may also determine who "goes" first.)?) I'm not saying that Trig couldn't become enmeshed in a situation like that, but I'd think that his age would be a plus under Dr. Emanuel's guidelines, and I see nothing in his paper that suggests his Down's Syndrome would work against him. (Perhaps that's because I read "prognosis" as referring to the acute condition that brought Trig into the hospital--will the expensive treatment bring him back to where he was before he was shot/his liver failed, or will he still suffer & possibly die because of it, regardless of our efforts?), rather than as judging the worth of his whole life, mental acuity included.

    Assuming you state his view accurately (I haven't the time to read the whole paper now, but I intend to), I agree with the Doc, by the way... When resources (doctors, equipment, organs for transplant) are scarce, choices are made. Happens in hospitals right now, and it will continue to no matter what happens with this health care reform. In a finite system, the patient you have a good shot of saving gets more of those scarce resources than the patient that just isn't going to make it, especially in acute, emergency care situations.

    The less immediately dire the health threat, the more that can be offset by patient/family money--and I don't think that'll change under the proposed reforms, btw--but when you're freshly shot or suffering a heart attack, your recovery (or survival) has alot to do with which hospital is closest to you, and what other patients happen to be there at the time. On a good night, you'll get the head of the department; on a busy night, you may get the newest intern. It's all supply and demand, and the luck of the draw.

    From what I did read of the paper though, it's apparent that it is
    a mostly theoretical exercise that assumes scarcity of resources as a given. It's the equivalent of discussing who you would keep and who you would toss off the overcrowded, sinking lifeboat, or whether you would rescue the doctor on the verge of finding a cure for cancer or the toddler, assuming you could only rescue one of 'em, and knowing the other would surely die.

    ALL of the systems discussed in the paper (the one used by UNOS, the one endorsed by the World Health Organization) evaluate patients to determine who should get the treatment and who shouldn't. All of 'em have "winners" -- those who will get the liver or heart and will live, and "losers"-- who will not get the transplant and will likely die, and all of 'em propose some method of judging who the "winners" and "losers" should be. (If need be, I can seek out & post the equally disturbing choices the other medical ethics systems--systems in place as we speak, I might add--suggest for judging who should live and who should die.)

    You & Sarah are welcome to your opinions and your fears, of course, but I don't agree with your thoughts on this.

  26. There is a very good post here By Walter Williams on some of the ramifications of this debate:


  27. Intellectual dishonesty in defense of Sarah Palin is just an embarrassment. There is (by definition) no relation between Emmanuel's ethical reflections and non-existent legislation.

    To say "To that extent, Palin's comments properly are viewed as a warning shot not to move to Dr. Emanuel's concept of health care rationing based on societal worth, rather than a critique of a specific bill ready for vote," is a clever way for Jacobson to clean up Palin's mess, but it hardly does justice to the stupidity of her saying it in the way that she did.

  28. Dear Prof. Jacobson,

    You wrote, "Will such a commission decide to curtail allocation of resources to those who are not deemed capable of "complete lives" based on prognosis and age, as proposed by Dr. Emanuel? There is no way to tell at this point since we do not have a final Democratic proposal, or know who would be appointed to such a commission."

    Actually, the commission already exists -- look it up. Their meetings are open, and their reports are published on the web for all to see.

    There is a long and honorable history of rationing of health care in this country (and elsewhere). In the 1970's dialysis machines were brand new, very expensive, and there were not enough to go around. Committees decided who would get dialysis, using criteria that (as I recall) were not radically different from those proposed by Dr. Emanuel.

    Of course, what was the alternative? Should we have held an auction and award dialysis to the highest bidder? If you believe the right wing theology -- that money equals virtue -- then that probably sounds like a good idea.

    Perhaps, instead, we should have held a lottery, the winners getting dialysis. This is ethically superior, but heartbreaking if someone who is terminally ill from unrelated causes wins and uses one of the slots. This could cause someone with a good long-term prognosis to die from a lack of treatment.

  29. @ThomasD - The must succint answer to the "well, insurance companies already decide for you", strawman argument. Absolutely wrong - WE decide, through the type of coverage we choose to pay for. The "mean insurance company" meme only comes about when they are holding to the contract the WE chose to make with them - and not giving into the "but I deserve it all" attitude so prevalent in our entitlement-ridden society today.

  30. What should be scary to all about Dr. Emanuel's words is that they sound eerily familiar,

    "The underlying motive was the desire to help individuals who could not help themselves and were thus prolonging their lives in torment. ... To quote Hippocrates today is to proclaim that invalids and persons in great pain should never be given poison. But any modern doctor who makes so rhetorical a declaration without qualification is either a liar or a hypocrite. ... I never intended anything more than or believed I was doing anything but abbreviating the tortured existence of such unhappy creatures…… I am convinced that today they have overcome their distress and personally believe that the dead members of their families were given a happy release from their sufferings."

    Testimony of Dr. Karl Brandt, Nuremberg War Crimes Trials, Adolf Hitler’s personal physician. Sentenced to death and executed June 2, 1948 at Landsberg prison in Bavaria.

  31. Really, Lew? A Nazi doctor?

    Where does Dr. Emanuel suggest ending anyone's suffering by taking any active step to kill them? Please quote and cite it.

    At best (or worst, depending) this is about the allocation of limited resources in the face of multiple patients who all need the same resource to improve their health or (most often) save their life.

    It's not about deciding whether or not a patient will likely die; there's one heart, and two or more patients who need one to survive the next 24-48 hours. Somebody will live, and somebody will likely die. Dr. Emanuel's article discusses four different systems of medical ethics for fairly determining who gets the heart.

    Perhaps it would be instructive if all the people upset about Dr. Emanuel's suggested method for making this decision were to choose which of the other three ethical systems (or one they create themselves) they support for doing so, and whether the rest of us wouldn't find elements of it (the parts about "...who should therefore not get the heart," especially) equally distasteful.

  32. There will be such a "death panel." Check page 58 of hb 3200. "(D)....whether the individual is eligible for specific service with a specific physician at a specific facility..." This is in an area of discussion related to use of computers!!

  33. Sorry repsac, I said his words SOUND eerily familiar, not that they were exact.

    Should this pass into law and as expected, healthcare is rationed, as it most certainly would have to be, any guess who would be the first on the list to be denied?

    Do you really want some bureaucrat deciding if your life, or that of a child of yours, merits receiving healthcare based upon what they deem to be "liveable?"

    A New York TImes op-ed you might like to read, http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html

    And yes, pay particular notice to who authored it.

  34. Dr. Ezekiel Emanuel is also an opponent of physician-assisted suicide. Which, if we assume that his beliefs are to guide the intended policies of President Obama, means that euthanasia would never be a part of health care reform under Obama's administration.


  35. PatD said:

    'Take prostate cancer. There are 186,000 new cases per year in the US. In the US, 170,000 of those men would still be alive after 5 years. If we had the NHS system, only 95,000 would survive 5 years.'

    This of course is nonsense. The reason for higher survival rates in the Us is that you aggressively screen for cancer and uncover more cancers that are slow to progress or that do not threaten life at all. The actual mortality rates from prostate cancer are much closer, and indeed better in some European countries than in the US.

  36. I am very impressed with this site and plan to come back often. but I have one question, why do you have an 'Obama Kitsch' link? It's seems like a trivial attempt at humor and even if you are not impressed with Obama, he is our president and deserve a certain amount of respect. I expected more from repulicans! As a citizen I am extremely tired of the bullying and name calling and any-thing-goes politics we have come to. Can't we debate without all the brutality?

  37. Having READ HB (house bill) 3200, just as Sarah Palin HAS READ HB 3200, and after reading some of the posted comments here, IT IS VERY APPARENT that few, if any, of the left nutters bothered to read HOUSE BILL 3200, which is the bill that is trying to be forced through congress by palosi and her demo-wit-less NAZI's... backed by the false-president obama...

  38. And just to add: the complete fabrication of the right here is that health reform would reduce care for the disadvantaged, millions of whom are already shamefully treated in American society, when it's principal aim is exactly the opposite. The lies are so transparent it's amazing anyone with an ounce of moral heart falls for them.

    As for evidence of effectiveness, why on Earth wouldn't you want to know what works and for whom? Do you honestly believe it's preferable to send say 80 year olds for open heart surgery that has no record of lasting benefit? And if you chose to ignore the evidence, do you really believe your right to pay anyway will be removed?

  39. Marcb, Similar stats apply to all cancers. I focused on prostate cancer because my father was "treated" in a socialist system modeled on the UK system (New Zealand) and died after his prostate cancer metastasized. Had he lived in the US, his chances would have been much better.

    Check this post at http://mjperry.blogspot.com/2007/10/us-cancer-survival-rates-are-lowest-in.html

    According to the survey of cancer survival rates in Europe and the United States, published recently in Lancet Oncology:

    1. American women have a 63% chance of living at least five years after a cancer diagnosis, compared to 56% for European women and 53% for British women.

    2. American men have a five-year survival rate of 66% compared to only 47 percent for European men and 45% for British men.

    3. These figures reflect the care available to all Americans, not just those with private health coverage.

    4. Great Britain, known for its 50-year-old government-run, universal health care system -the National Health Service - (portrayed extremely favorably in Michael Moore's movie "Sicko") fares even worse than the European averages, and far below U.S. averages (see chart above).

    5. Despite the large number of uninsured, cancer patients in the United States are most likely to be screened regularly, and once diagnosed, have the fastest access to treatment.

    The study concludes that "International comparisons establish that the most important factors in cancer survival are early diagnosis, time to treatment and access to the most effective drugs. Some uninsured cancer patients in the United States encounter problems with timely treatment and access, but a far larger proportion of cancer patients in Europe face these troubles. No country on the globe does as good a job overall as the United States."
    Post Obama-care, everyone will be worse off. US R&D will dry up due to price controls on drugs and treatment. Other counties will be left without the US to subsidize their drug costs.

  40. Did any of you who are hysterically crying "death panel" bother to note the SUBJECT of this study? It's about the allocation of "SCARCE medical interventions." In plain terms, it's called TRIAGE. But not in the general sense like you see on ER. It is a study of a very particular and small segment of the entire spectrum of health care triage issues. The paper has three authors and cites 97 references from thousands of similar Bioethical studies that have been published since the dawn of medicine. How many Bioethical research papers have you read? Did you look up any of the referenced articles in this study? The principals and ideas put forth in this study are not new and are, if fact, pretty standard for bioethical research.

    As uncomfortable as it may be for you and I to think about, medical TRIAGE criteria must be studied constantly, it must be discussed in a million different scenarios and from as many diverse vantage points as possible. This important research will continue, as it should, especially given the technological advances of the last 60 years.

    I have been a medical practitioner for 30 years, much of it spent in the Newborn ICU. Do I have a foundation of knowledge and experience in the ethics of triage from which to speak? You betcha.

    The way in which this article and the content of the Obama adminstration's health care reform proposal has been shredded and blatantly distorted by mainstream America, almost makes me long for the hard-core secrecy policies of the Bush administration. Almost.

  41. @truthrocks - "Scarce medical interventions" is the very issue the Obama administration is dealing with in formulating a plan which does not have enough resources by design (called cost cutting). So the type of choices being addressed by Dr. Emanuel are analogous to the types of choices the administration faces, and the methodology selected by Dr. Emanuel speaks for itself. Again, these are his words, not mine. I would not expect any politician to agree with the "complete life" approach, but that is why the politicians want to offload the hard decisions to a panel of experts similar to MedPAC.

  42. It might help if you actually mentioned some details about Down's syndrome, because then your readers would realize that it's only moderate as far as genetic disorders go, and most babies with it can live functional lives. Visit any pro-life website and they will tell you so.

    I think most people are objecting to Palin's implication that Down's syndrome (of which there are a fair number of individuals afflicted) is serious enough to be considered a "euthanizeable" condition. There's only a thin line between euthanizing down's syndrome individuals and people with naturally lower-than-average intelligence, and Palin's implication that the government would EVER consider that is totally absurd. Saying our government, or the democratic party, is capable of such a thing is pretty blatant political slander.

  43. Per NY Times, 90% of women who receive a test result that their unborn child has Down Syndrome choose to abort, http://www.nytimes.com/2007/05/09/us/09down.html.

  44. The left in the USA are mad if they really believe that millions are dying under the current system. Their argument is a real straw man.

    We should not confuse the euthanasia issue with other life and death issues. Someone mentioned the Texas bill and ranted about it being the work of the Republicans. This is one that needs to be put into perspective. The people so affected had no chance of survival if their life support was turned off, at least in the cases that I have read about. This is a far cry from withdrawing food and water from people who are breathing on their own (Schiavo) causing them one hellish death through starvation and dehydration. A small child on life support where there is no known cure, and who cannot survive without the life-support is a very different case from someone like Schiavo who was not brain dead as some left loonies continue to claim (the woman was awake according to the hospital report and it was Dr. Death Cranfield who claimed that she was brain dead - not a good source of opinion because he was making a living out of killing people).

    Rationing of resources can be a very bad thing. Take for example someone who is badly burned in a car crash where the alternative is to cut off her leg or let her die. If that person was elderly would the hospital panel just let her die? This is not a good example but is partially based upon a real scenario where the person did have her leg cut off to save her life.

    Most people require basic health care. In most cases of common cold a doctor's attention is not required. Even cuts etc do not need the attention of a doctor unless there is evidence that a stitch or two is required. However, there are many people who have other forms of disease including arthritis, diabetes, etc. etc. Some argue that these are lifestyle diseases - maybe or maybe not because some forms of arthritis are in fact genetic. The treatment for some of these diseases is costly. In fact in Australia you cannot get hold of certain forms of medication for ankylosing spondylitis (a form of arthritis that is hereditary) unless you meet certain government criteria. It is too bad that the treatment works best in the early stages of the disease when it has the best chance of halting its progression. In the USA it is the insurance company that has to agree to the patient getting these medications.

    There are already a lot of hang ups for these patients being eligible for disability. In the end they do win their cases but it takes time. In Australia you cannot get disability if household income is over a certain figure. This means that if you require expensive medicine and you do not have enough money to afford that medication you miss out. This is how the middle class are treated in a government healthcare system.

    In the situations I cite these are not life-threatening situations but for many patients there is a lot of pain, and it is hard to cope with that level of pain. For those patients the medication can help to soothe the pain levels, yet they are denied the medication because they either do not meet the criteria laid down by the government or because they cannot get disability because of income limits that exist.

    The whole idea that millions have died because of the present USA system is absolute baloney. It is nothing more than the Democrats and Obama creating smoke. Women these days are not at risk of dying when pregnant unless they are foolish enough to take RU486 and increase their risks of getting a fatal condition by almost 100 per cent. There are just many diseases such as cystic fibrosis where the person will die at a young age, and that is because research into the disease is not advanced.

  45. @main gauche - you are only telling half of the story.

    Many of the babies born with Down Syndrome have other heart conditions that could cost them their lives. I know because I have known several families with Downs babies and I would say that in most there had been serious heart conditions that required early surgery.

    I think that this is the kind of scenario that Palin would have been considering. You see if the doctors refused to do the surgery then the children would have died rather than leading fully functioning lives like so many of them are experiencing today.

  46. We have universal care in Canada. It's quite good. Not once have I seen or heard of a "death panel" that would refuse care.

    In fact... in the case of both my father and mother, they tried to prolong their lives in such a way that arguable increased their suffering. Only when my Mom requested that she not be revived should her heart fail did they step back.

    That said, what exactly would you call an insurance company that refuses to pay for treatment? If this isn't a "death panel", I don't know what is.

    Stop lying.

  47. @John,

    it was a different experience for my father. The doctors were pressuring my mother and family members to agree to a DNR when he had the second stroke. This is what happens when resources become rationed.

    I have heard good and bad things about the Canadian system. Anecdotal evidence seems to be on the whole good, but that does not mean that the system is perfect. There is still going to be rationing of resources and that includes the scheduling of operations such as necessary eye surgery that is considered to be elective.

    My beef with the system has always been the fact that the government interference has meant that we no longer have all of the necessary choices like we did before the interference. Prior to the introduction of Medibank for example the poor were treated in the public hospitals and they were not turned away. At the same time the GPs in the suburbs would often see low income people on a pro bono basis. They used to spend more time with their patients but as a result of that interference you get about a 10 minute appointment that costs over $55 and the schedule fee is a lot less than the charge which means you need to have at least $55 to see the doctor in the first place, and only get back something like $30. For specialists the amount required to see one is over $100 and ditto with the scheduled fee so that one is very out of pocket. On top of that essential services such as physiotherapy etc. are not covered. The health funds will only cover a fraction of the cost of the physiotherapy in private practice. It means more out of pocket expenses and yes it gets to the point where it has to be discontinued because of the lack of finances to cover what is necessary.

    Medications are another nightmare. Even if they are on the free list, if you are not on a health benefits card of some sort you have to pay over $30 per prescription in most cases. If the item is not covered by the PBS scheme then the cost can be extraordinarily high - over $100 - for necessary medication such as Lyrica for nerve pain. These costs are not sustainable so one has to just do without the medication. That is the reality of a government run scheme.

  48. @John,

    the kind of treatment where the health insurance company refuses to pay might include an expensive drug to treat a form of arthritis. It does not involve a life or death situation.

    There have always been limits upon what the health insurance industry will cover and they have the right to refuse payment for new and expensive treatment or diagnostics.

    This is not the same as a situation where the person might fit into the very disabled class in the first place e.g. a Down's Syndrome baby with a heart condition. It is in fact well known that there are doctors and nurses who already play god by smothering these babies to death in their first few hours of life.

    The whole situation gets very tricky and if government is allowed to start making these decisions then certain classes of people will suddenly find that they are in fact worse off and not better off. In other words inherent biases will exist and these biases will determine who gets treatment and who misses out.

    I cannot compare the Australian system to what is being proposed. Ditto for comparing the Canadian or British system. Without seeing the proposed legislation we cannot say anyone is lying because there are a lot of hidden clauses and that means no one is lying except those who are hiding the truth from the general population in the hope of getting their eugenics passed into law.

  49. Everyone should read the referenced paper for themselves. It is a medical ethics paper discussing what to do in cases of scarce medical situations like having 1 organ for transplant, but 4 people who need it. Given that situation, how do you decide who gets it? There has to be some mechanism for deciding - that's what this paper is discussing, nothing more. Under the approach recommended it even sounds like Trig would have better odds than other approaches as he is very young.

    Here is the executive summary of the paper:

    "Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles."

  50. The key point here is that Obama has never proposed a "death panel" that would decide whether disabled people deserve health care. It is simply a bald-faced lie, and indefensible regardless of who said it.

  51. "These critics, however, didn't take the time to find out to what Palin was referring when she used the term "level of productivity in society" as being the basis for determining access to medical care."

    No, that's because Sarah Palin issues all of her statements from what might as well be "an undisclosed location"

    She doesn't make herself accessible to any but the occasional right wing leaning reporter, like Greta Van Susteren (who now seems to be bumped from Palin's "A" list) or Mike Allen, the Politico reporter she called at 10:45 PM from "Michaels' in NYC" to tell him what she was doing, where she was, and who she was with in a pathetic attempt to put her name in the news another day...

  52. Maggie, you said, "I think that this is the kind of scenario that Palin would have been considering."

    You don't know what Palin was referring to any more than William A. Jacobson does. Anyone who reads her statements can only GUESS what Palin means, because SHE NEVER EXPLAINS HERSELF. There are people still trying to figure out her obscure references in her "I Quit" speech from July 3rd.

  53. We really need to separate out some concepts here. "Euthanasia" is telling people to actively kill themselves or actively killing them in order to spare a burden on society. You could call the killing of 90% of babies found to have Down's Syndrome euthanasia. You could probably call most abortion euthanasia, in fact. You could also call the Oregon Department of Health's actions in denying a woman an experimental cancer medication and instead informing her that assisted suicide would be covered, euthanasia.

    On the other hand, Palin's "Death Panel" is a rhetorical concept of a group that decides when to deny care, whether as a policy or in specific cases. This is not euthanasia, which actively kills people. This is certain people being empowered by the government to decide when and under what circumstances people will receive care. Such decisions could lead to death. It is a feature of EVERY single-payer health system because resources to provide health care are limited.

    This is where Dr. Emanuel's article comes in: He talks about what to do when there are limited resources available. Which is exactly what Palin is speaking of, what will happen when there are limited resources available. The laws of economics prove that resources under national healthcare will be more limited than today: As more people demand a good (healthcare services), the price of the good will rise. If the price of the good is artificially limited (Medicare reimbursement), there will not be enough of it. This is extremely basic.

    The difference between an insurance company is that I can sue my insurance company if they are screwing me over. I am constitutionally prohibited from suing my government without its express permission, and there is no provision in the current HR 3200 that allows me to sue my government.

    The "End-of-life" panels on p. 424 are upsetting to me because I know how easily led my grandmothers are. If a government representative routinely visited her to "counsel" her on end-of-life issues, she would very liekly be easily led to sign a piece of paper ordering the hospital not to resuscitate her. The wording of the provision is very much "shall" and not "may"; these are not permissive meetings, they are mandatory. And they are creepy, particularly where they are to occur more than once. That provision ought to be excised from the final bill text.

    If insurance companies are the problem, then we should fix that problem. Setting up a system that is designed to force the private insurers to go out of business is a bad idea. Further, the people who designed the system on HR 3200 have previously advocated single-payer and called this a stepping-stone now tell me I don't need to worry because this isn't actually single-payer. This is incredibly deceitful and they must think I'm stupid not to be able to make the connection. If I don't want single-payer, I have to fight this. It's that simple.

  54. AHEFT shows African American health care has long been rationed by breeding us to limit our lives, so why should we pay for all those boomer pensions we will never benefit from? After all, it was the boomer pensions which caused the market to crash.

  55. AHEFT shows African American health care has long been rationed by breeding us to limit our lives, so why should we pay for all those boomer pensions we will never benefit from? After all, it was the boomer pensions which caused the market to crash.

  56. It's disengenuous to assert that care cannot be rationed in some way. Either everyone gets less care overall but at least everyone gets some care, or some people get more care than others and we have to pick some method to decide who gets it and who doesn't. There are simply not enough resources to go around to the extent that every person gets the best care available all the time for every illness.

    If you think care should be rationed along economic lines then you are probably opposed to Emanuel's idea. If you prefer to repeat the phrase "the market should decide" ad nauseum you'd also probably prefer the current system to Emanuel's until you need to see a doctor and can't afford to. If you think distributing care resources along economic lines is unfair, then probably Dr. Emanuel makes some sense.

    In any case, whatever Palin might have "meant" by the term "deathpanel" it seems quite a stretch to characterize her sentiments as other than self-serving.

  57. So let me get this straight. The author of this blog admits that we have no way of knowing whether a commission that Obama said he was "open" to will be in the final bill, nor what kinds of factors it might consider in reaching its determinations. And yet he defends Palin's claim of an "Obama's 'death panel'" making decsions about someones worth to society?

    Since when did such rampant speculation about what might be in a bill pass for serious analysis? Palin's use of those phrases was not an attempt to look at the issues. It was fearmongering. If we want to debate certain issues regarding medical care, well and good. But it's hard to see Palin's statements as anything other than an attempt to rile up the conservative base to block reform.

  58. I'd never heard or read this blog before today.

    Good lord, sir, you're either a brilliant propagandist or an abject idiot! Congrats: I'm sure you'll find lots of success catering to the right wing internet.

    Martin L. Morgan

  59. In Oregon, as it stands, if a patient has a less than 5% expectation of survival for 5 years, the insurance panel may decide to withold payment for further treatments. I believe this is what many people are afraid of.

    It exists, and this is the concept espoused by Dr. Emmanuel.

  60. Again, we get trapped in arguments about money and numbers of people and service quality, when the most fundamental question is, "Does the White House have the Constitutional authority to provide health care to the electorate, and does Congress have the power to fund it?"

    Any reasonable reading of the Constitution leads to the conclusion that they do not, and therefore, any discussion of Federal health care initiatives should start with passing a Constitutional amendment granting these powers to the federal government.

    Until then, all this bickering over details is really putting the cart before the horse.



  62. @squid,
    that is an excellent point. So why is it that most Americans are not aware that the Federal government does not have the constitutional authority to be so meddlesome in the first place?

  63. @Maggie/squid:

    I don't think you folks know the Constitution very well. Supreme Court precedent makes it pretty clear that the federal government has the authority to do what is being proposed.

    Farm subsidies are not unconstitutional (and that has been the case since the New Deal). Medicare is not unconstitutional. Subsidies for medical insurance would not be unconstitutional, nor would incentives for more efficient delivery of medical services. Medical care is certainly a part of interstate commerce, and therefore falls under Congress's power under the Commerce Clause.

    It helps to read the case law before making assertions about what is or is not allowed under the Constitution. You may not like it, but that's the law as it stands today.

    And Squid, the question is not "Does the White House have the Constitutional authority to provide health care to the electorate, and does Congress have the power to fund it?" That's not how the government works. Congress passes a law, and then the executive branch carries it out.

  64. First appointment to Death Panel.



  65. My family has spent some time on a government program called WIC (Women, Infants, and Children). It provides vouchers for milk, eggs, cheese, and other foods for children under 5 and pregnant or nursing women who meet their income guidelines. In theory this is to help them get sufficient nutrition.

    My son is lactose intolerant, so when we went to the WIC clinic we asked if they could give us vouchers for soy milk instead of regular milk. On the WIC website it said this was possible. Our WIC office said they would not do it because it was too much paperwork. So for my lactose intolerant son they gave us vouchers for milk, all the milk we could possibly want him to drink if he could drink milk.

    Why do I bring this up? Because a lot of the pro-Obamacare people on here keep saying that the law doesn't require this and the law doesn't require that. It's not about what the law requires, it's about what you're likely to get at your local office. And your local office may be staffed with the most loving, caring people who will go to any lengths to help you. But the smart money's on your local office being staffed with people ignorant of their own policies and merely responding to their own incentives, or even worse, people who just don't give a crap about you because there are 11 more people just like you in line behind you and the job pays the bills. This is how government works when the size of the bureaucracy expands past the size of the competent and caring population.

    It's all very well to sit in your armchair and with erudition expound on the technicalities of how the law would be administered if you were in charge of every detail. You may feel perfectly comfortable with Dr. Emmanuel making your health care decisions. But since neither he nor you are available to staff every office, you should at least consider whether you would want this law if it were administered by Linda The Petty Office Manager, Monica The Childless 21-Year-Old Social Worker and Patty The Vindictive B!tch. Because they're the ones going to be staffing your local office.

    Also, I'm really sick of the argument "We don't have 4, silly Teabaggers, we just have 1 and 1 and 1 and 1. Maybe you're thinking if we arranged the 1's in the shape of a 4? How cute, what grade are you in?" Kindly expand your time horizon to farther out than 30 seconds after the bill becomes law, please, and don't insult my intelligence by telling me nothing about my health plan will ever change since it won't change in the 30 seconds after passage.

  66. Wacky Hermit: "It's not about what the law requires, it's about what you're likely to get at your local office."

    Yes, one can run into recalcitrant government bureaucrats. One can, and does, also run into recalcitrant administrators for private insurance companies.

    Yes, some things might change with health care reform. But some things might change with your life situation without health care reform. Like your share of the premium keeps rising faster than your pay increases. Or your employer stops offering it because it's too expensive. Or you lose your job and can't find another one that offers insurance. And if you have a preexisting condition and lose your job, forget about being insurable.

    I'd advise that it may be worth "expanding your time horizon" beyond present circumstances, which may not last forever.

  67. @Squid,

    Why, that would be somewhere around Article I, Section 8. Something about "general welfare" and all that.

  68. Turns out that the Death Panel came from a Republican. Specifically, Johnny Isaakson of Georgia. Ha! Nutcases!

  69. Wacky Hermit, what are you doing leeching off the government? Do what the Republican Party wants you to do and go die somewhere.

  70. Ah, the latest talking point. Found a Republican in favor of end of life planning, but if you read Palin's entire statement she cites Dr. Emanuel by name. Did Isaakson ghost write the embedded article?

  71. I like what Squid said, but Congress is past the point of caring what the Constitution permits or prescribes.
    It is easy to see why critics would attack Palin for her statements. Controversial to say the least. But then, many of her critics would jump all over her for saying anything. So when a statement should actually make someone think/ponder the ramifications of government run health care, the pain would too much for most critics and they would jast as soon attack.
    Now for the interesting part,,,,and it is simple. Would there be a govt. body that makes policy and financial decisions based upon budgets? You betcha. How would the resources be allocated? That' is what the Democrats DON'T want to talk about. Even Obama drifted off message and indicated that a pain pill might be the only choice instead of life-saving operation for an elderly grandmother.
    To believe that ANY commission won't be politically swayed or manipulated is riduculous also. The FCC has made policy changes in order to put a strangle hold on radio stations that carry programs with conservative, rightest views. All in the interest of the PUBLIC GOOD.
    We have neither the financial capitol nor the health care infrastructure to support the deformed health care system proposed by congress, yet they would push it through for the enormous amount of political leverage they would have once a large portion of Americans are beholding to the govt. for their "free" care. Instantly, a good 30% (and growing, thanks to provisions in the bill) of our population will be scared at every election that the Repulicans will take their health care away. Next, of course, comes amnesty for illegal aliens. Instantly, 10-20 million new voters for Dems. Somewhere in that time frame, talk radio is reduced in scope and availability. Not completely because the Dems will be careful to say they did NOTHING to STOP free speech. It's in the cards and has been planned for a long time. The power brokers just needed someone who could sway a huge portion of the population with smooth talking and a nice face. Hillary wasn't going to get it done,,,,,but this guy Obama looks to be the ticket.
    Bottom line: Universal health care is a populist idea that is not grounded in any sort of reality. Cost decisions must be made. Some will be left out. Who will they be?

  72. @ William (August 10, 2009 10:15 PM):

    I think the point of that "talking point" is, what Dr. Emanuel wrote in the embedded article isn't what's in the health care bill. What Rep. Isaakson wrote, is. What Sarah Palin said about "death panels," was in reference to Isaakson's addition to the bill. The whole question of Dr. Emanuel's article or judging anyone by their "level of productivity in society" is kinda moot--except as an intellectual exercise--because nothing in the embedded article is actually in the health care bills being proposed.

    @ alwaysfiredup (August 10, 2009 11:56 AM): As regards your definition of death panels - What you describe exists in every health insurance company and most hospitals already. It's not just a part of every single-payer system; it's a part of EVERY system. Decisions are made by the providers of the actual health care (doctors & administrators), and providers of the money to pay for it (insurance company bean-counters and bureaucrats). To whatever extent the government (us) is paying for the health care, we have a right to decide under what circumstances the money starts and stops. (Personally, I trust we, the people, more than folks who're beholden to profits and shareholders.)

    And again, Dr Emanuel isn't talking about every aspirin and band-aid. His article is about acute, life or death situations where "who's paying for it?" isn't the issue. There's only one heart, and more than one person who will die in the next 24 hours without one. (Except black market, I guess), one can't just run down to "hearts-r-us" and pick one up, regardless of whether they can pay for it out of their own pocket, have private health insurance, or the government is picking up the whole tab.

    The way I see it, this is about creating a floor, not a ceiling. Those who can pay for it can and will always be able to get the "best" health care. These reforms are about getting adequate care for everyone else. Yeah, I suppose there will be procedures and drugs that the government won't pay for, but as someone who's had insurance companies disallow drugs that my doctor prescribed, I don't see this as a big change. Some pencil-pusher is already getting between me & my doctor and determining my care.

    As for suing your insurance company, the unfortunate fact is it'll likely be your next of kin brining the lawsuit, and unless s/he's well-heeled enough to afford a team of lawyers, probably losing the case, besides. I don't know the facts about not being able to sue the government (but your claim sounds "fishy" to me--I'll read up), but I'd imagine the public outcry over denials that cause folks to die would bring about changes in a government plan quicker than in a private plan. (No non-disclosure settlements.)

    Now as far as those "end-of-life" chats, I'm against any language making the chats themselves or their content mandatory. I wouldn't (at this stage, anyway) be opposed to signage and a document stating the facts about living wills and whatnot, specifying that the patient can discuss this such things with their doctor, and that if cost is an issue, the government will pay for that discussion. A take home hand out for everyone over 18--because anyone can be hit by a bus & left in a coma--and a yearly signed receipt of having received it would be fine. I wouldn't be opposed to a doctor choosing to bring it up, either. But I don't believe the government needs to be in the room mandating the conversation. (Of course, I feel the same way about abortion providers and those mandatory counseling sessions some states propose or have written into law.) Here are the facts about your options, and we'll be glad to discuss them with you ("at gov't expense," in the case of living wills & end of life care), if you so desire. Please sign & return this page stating that you received this pamphlet.

  73. So, first, you assume without any warrant that an article discussing current allocation systems is part of some you-cannot-name Democrat proposal because the author happens to be related to someone in politics.

    Then you ignore the fact that he's talking about allocation of scarce resources now on the basis of how fat your wallet is.

    So, in sum, you think rich people should live and poor people should die.

    Is that a fair summary of your plan?

    You avoid a "death panel" by assuming all poor people should die!

    How clever.

  74. The public discussions of “death panels” and health care allocation schemes are often being conducted so far away from reality that it’s a wonder they haven’t been vaporized by Klingon death rays. I ran with an emergency squad for more than three decades, and (not frequently but often enough to worry about) we would have to act as a de facto “death panel” (in the idiot conception that Sarah Palin conceives of it) on a multi-victim accident scene, deciding who would be treated immediately and who would be left to die while others are being treated.

    That’s called “triage” and it’s a necessary component of any medical care system in which the needs exceed the resources. The only valid question at issue is how limited resources will be differentially allocated across patients, not whether they will be differentially allocated.

  75. I just want to say thanks for this article and I feel for you. I've posted on it, as well, and those critical haven't generally bothered to read the evidence. Keep up the good work. Oh, and I linked back.

  76. Mr. Darrell, our rights under the Constitution are negative. They aren't about what the gov't MUST do FOR us. They are about what the gov't must NOT do TO us. For instance, I have a right to own a gun. This doesn't mean the gov't must buy me a gun. I have a right to health care, but this doesn't mean the gov't must provide it. Because I have a right to health care, if the gov't plan causes ONE SINGLE DEATH whether by rationing or any other method that results in that death, it is unConstitutional. The gov't is about to embark on a health care plan ostensibly to save the economy, not to save lives. That is Obama's reasoning for it. If, in the name of efficiency, one single person is harmed by it, it (ironically) defies my right to health care. It's a perversion, what this president is going to do to our Constitutional rights all while the American people have forgotten what "rights" ARE.

  77. There seems to be a lot of confusion as to what Euthanasia means. First, there are several types of euthanasia. "Active" euthanasia, the type most people think of when they hear this term, refers to physician-assisted suicide. Simply put, a physician "actively" causes death through sometype of intervention. There is also "passive-active" euthanasia. This is when the treatment rendered can accelerate/cause death. The hospice modal of end-of-life care abounds with this type of euthanasia. This is usually associated with pallitive care, such as adminsitration of narcotics for pain management. It is a well known fact that narcotic angelisic lead to increased tolerance, meaning that, over time, more of the substance is needed to provide the same level of relief. It is also a known fact that long-term use and high doses of narcotics lead to respitory supression (slowing of breathing). This places a physicain in a delima: Continue to manage the patients pain with high dose narcotics, which lead to respitory supression and evantual death. Or discontinue the narcotics, allowing the patient to suffer in pain; but life is prolonged. Finally, there is "passive" euthanasia, which means that life-saving medical treatment is withheld and the natural course of the diease leads to death. An example of this was the common practice in the early 70's and prior not to treat newborn children with Down's Syndrome for a common condition where the stomach and intestines were blocked by a growth. THe treatment for this was a simple surgical procedure that open-up the blockage allowing the digestinal track to function normally. Oftentimes, the condition was not treated and the newborn died a few days after birth from starvation. This practice was ended with a Supreme Court ruling that mandated the life-saving treatment. I believe the case was Baby Doe v. Blossom Indiana Hospital (or something simular)and was decided shortly after Roe v. Wade. The legal princible was that that quality of life was individual and parents or hospitals did not have the right to make that decision on behalf of a child, if a clear and safe medical procedure was avaible that would save the infants life (the premise was that the deicision to forego minor stomach surgery common in infants with Down's Syndrome, was rendered because of the reiduals associated with Down's Syndrome, not the easily treated stomach condition).

    The current healthcare bill being debated by Congress contians provisions supporting two of the three types of euthanasia: passive-active and passive (witholding care).

    I guess 2 out of three ani't bad.....

  78. Ms. Graas said: Mr. Darrell, our rights under the Constitution are negative. They aren't about what the gov't MUST do FOR us. They are about what the gov't must NOT do TO us. For instance, I have a right to own a gun. This doesn't mean the gov't must buy me a gun. I have a right to health care, but this doesn't mean the gov't must provide it.

    Our Constitution establishes limited government, yes. That doesn't make rights negative (as if that has meaning . . .). If someone moves to interfere with your right to vote in elections, the government has a duty to act to preserve the rights. "Governments are established among men" for just such purposes.

    Because I have a right to health care, if the gov't plan causes ONE SINGLE DEATH whether by rationing or any other method that results in that death, it is unConstitutional.

    And I am Marie, the Queen of Romania.

    That's about as bizarre a claim in law as I've ever seen.

    The gov't is about to embark on a health care plan ostensibly to save the economy, not to save lives. That is Obama's reasoning for it.

    Right, which is why Truman worked on the idea, Johnson worked on the idea, Nixon worked on the idea, and Clinton worked on the idea. They were trying to save the economy in 2009.

    There is ample evidence of the need to fix our health care system -- in only in this: The 50 million Americans who don't have access to health care? We pay $300 billion to buy them care. They just don't get it.

    If we could stop that wastage, it would be a very, very good thing.

    If, in the name of efficiency, one single person is harmed by it, it (ironically) defies my right to health care.

    Today in Dallas "death panels" made decisions in more than a dozen cases. Same with every other major city in America. Why don't those actions, driven by a private system of rationing, defy your right to health care as well?

    Why is a private bureaucrat who works for a lot of money more holy than a public bureaucrat wh works to be fair?

    I'll take fairness over fat profits for business execs any day.

    It's a perversion, what this president is going to do to our Constitutional rights all while the American people have forgotten what "rights" ARE.

    Really? How does any part of H.R. 3200 do that?

    Some Americans have forgotten their rights, I'm sure. As you've amply demonstrated, others never had a grasp on what they were, or how or why they should be protected.

  79. So arguably, both insurance companies and a MedPAC bureaucracy would benefit by allocating 'withholding' medical resources. They both save money.

    The difference though seems that insurance companies would gain/capitalize from your livelihood as opposed to government, which basic and efficient as it is doesn't benefit from giving costly and unnecessary procedures. Note the word "unnecessary" is often being thrown out to label this and that for whatever procedure for economical means to make the whole system work.
    Obama even just recently anecdotally listed tonsillectomies as a causeless procedure pediatricians performed on a regular basis to profit from. Matter of fact, physicians who often make the suggestions don't always perform the operation and 'profit', but the point is this is essentially what government does, standardize/contract out of cost of effectiveness and necessity.

    Although the current system is not perfect, no one can deny the developments in medicine that are now available due to free market and pharma companies. It's a marvel how many people come around the world to see specialists in this country. This whole castigatory mindset against doctors certainly isn't aiding healthcare either...

  80. I am not a Democrat or Republican. I am an American. On the Section 1233 debate I think some people are so passionate about being against Obama that they are reading too much into this section. Just read Section 1233. It's not that long or hard to understand. I don't understand how some people are getting confused about what it actually says. I don't see how people believe this section will get interpreted as saying kill all seniors to save money. It's OK to stay abreast of all the left and right wing commentary, but read it for yourself and do your own fact checking.

    Advanced Care Planning Consultation

  81. No one seems to be addressing the fact that there will be a future problem with the allocation of scarce resources. Just as your HMO makes decisions today, there will be decisions in the future that will be made by bureaucrats attempting to save money. This will inevitably mean that operations and medications will be denied to people. It might be to the elderly or it might be some very severely disabled person. The fact is that there are people who are very much into eugenics and if the proposals go forward there will be less chance to prevent the elderly and the disabled being rounded up and given the German solution.

    What most of you do not seem to understand is that prior to World War 2, when the final solution was implemented, Hitler rounded up the disabled, took them to hospitals and gassed them. That of course is an extreme method of dealing with the problem, and I do not forsee that happening in the USA but what can happen is that the denial of medical care will ensure that people will face a shorter life expectation than would be the case without that bill.

    Some commentators on this blog do not seem to be able to comprehend that this is possible. Well, I am living in Australia where there is a government health plan. There are limited resources and there is real interference with our health care. In Australia it is the states that are responsible for the budget of public hospitals, and in every State there is a crisis because not enough money is being allocated. This means the closing down of hospital beds, it means overworked doctors and nurses and a system that cannot cope with the demand by patients - a lot of people do not need to go to the emergency room and it is these people who are placing pressure on scarce resources.

    With a bill that relies on all sorts of committees for additional rules and regulations anything can happen. This is not good. You should be outraged over this proposal.

    I think it can be said that there is a need for reform, but the proposals are definitely not the kind of reform that you need.

  82. Did anyone read what Palin said? "And who will suffer the most when they ration care?" Where did that come from? She went from talking about what economist Thomas Sowell said (nothing to do with rationing) and then she changed the subject to rationing. Reminds me of the last administration, to defend their war in Iraq leading up to it, whenever they spoke of Saddam, the next line was always about al Qaeda - as if the two went together. Eventually, even though they never said the two were related, the public began to think they were the one and the same.

  83. "...no Government has the right, whether to flatter fanatics or in mere vagueness of mind to forge an instrument of tyranny and say that it will never be used." -- W. B. Yeats

  84. But Dr. Emanuel, who and where are these angels that are going to run this government program of yours? I don't even trust YOU to do that.

    RIP Milton Friedman!

  85. Let's let computers decide:


  86. Death Panels are REAL. Please check out this interview: