The Magazine

The New Third Rail

Why 'death panels' are a political killer.

Sep 21, 2009, Vol. 15, No. 01 • By TOD LINDBERG
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If Hogwarts were a school for politicians, there would be a required class on "Defense Against the Dark Arts of Demagoguery." President Obama considers his health reform effort a target of this dark art--indeed, he seems to view it as the main reason reform has faltered on Capitol Hill.

Here is the defense he mounted in his big speech to Congress this week:

"Some of people's concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Now, such a charge would be laughable if it weren't so cynical and irresponsible. It is a lie, plain and simple."

Professor Snape would not be impressed. At issue, of course, are the two words "death panels," uttered widely in opposition to Obamacare, most famously by Sarah Palin, the prominent politician to whom the president alluded. The phrase may indeed be "cynical" shorthand for a new government role in deciding on appropriate care as one nears the end of one's life; certainly it is polemical. And it may even be "irresponsible"--in exactly the same way that Democratic political operatives for decades have irresponsibly tried to frighten the elderly into believing Republicans were going to take away their Social Security benefits. But "laughable" is precisely what it isn't. End-of-life care is beginning to look a lot like a new third rail of American politics. Republicans will be happy to let Democrats learn this lesson the hard way.

Now, it is true that none of the proposed reform legislation calls for convening panels of government bureaucrats to make life-and-death decisions about the elderly on a case-by-case basis, with the power to shut off their medical care. Unfortunately for Obama, that doesn't make "death panels" a "lie, plain and simple." Rather, it is an exaggeration. When Obama responds to an obvious exaggeration with the rejoinder that it is not literally true, he is missing the point. The question is what this exaggeration is getting at. And the answer is that it is getting at something very real, the primal anxiety people feel about the end of their own lives.

It is just folly to pretend that this anxiety is anything but genuine among those who are getting on in years or who have received a diagnosis that looks to be life-threatening in the absence of treatment, and perhaps even with. And it is disingenuous in the extreme to pretend that the current reform effort doesn't have potentially large-scale implications for treatment decisions for the old and sick. Obama would like to ignore both points while blaming Republicans for making the whole thing up, but it won't work.

Since, as we all know, health care is expensive and the demand for it is vast, there has to be some way of settling the scarcity question. The current system is an unlovely hybrid with major deficiencies, but it has a couple of core virtues: Quality of care is first among them, but another important one is that for those with insurance or Medicare or Medicaid, care decisions are (within limits) mostly between people and their doctors, who take their Hippocratic Oath seriously. Even the limits have the virtue of being mostly known or knowable. True, people get unpleasant surprises from time to time about what's covered and what isn't; the system senselessly ties insurance to employment, inhibiting mobility, especially when "preexisting conditions" come into the picture. And it's not like the cost of insurance coverage and copays is going down. But there is an intelligibility and reliability to the system as it exists for those who are in it.

At a minimum, Obamacare introduces a major element of uncertainty. Of course nobody really knows what Obamacare is, including Obama; the term is a catch-all for whatever (if anything) Congress comes up with that the president can sign. But that's just another way of saying that overall uncertainty is high and rising, including on the issue of "end-of-life" care. And it won't do to try to alleviate the concern here by pointing to specific provisions of possible pieces of legislation and saying, "See, it's not there." Everything is up for grabs, and people don't like it when everything is up for grabs.

Then we have the more specific reasons for people to be concerned about who will be deciding what for them as they become sick or grow old. It is hardly fanciful to suppose that in a system in which resources are limited, global treatment protocols are going to decide eligibility for care in a way they do not currently. Likewise, people who are eligible for a particular treatment are going to have to wait in line until it's their turn. If there is any currently existing national health care system, such as the left dreams about, that does not contain these features, it's strange that no one has pointed to it to prove that health care, unlike everything else, need not involve tradeoffs.

The point for single-payer advocates, including in their "public option" guise, is that equality is the highest virtue, and that means equal access to what is available. It's simply unjust, in their view, that some people can afford high-quality care while others get none: If the price of a universal system is that some lose privileges they have long enjoyed, that's the kind of a tradeoff they are prepared to make.

But old folks and sick people in the current system, or people thinking about either prospect, may not see it that way. The question they have is, "What's going to happen to me?" The baseline they have is the care the system around them currently provides. They are right to worry about changes to the system.

To the general problem of the need to find a basis for allocating finite health care resources, one must add certain specific anxiety-inducing details that have come out in the debate: First, the inclusion in some of the early legislative language of provisions funding end-of-life counseling sessions--the objective correlative of the "death panel" polemics.

Second, the quick ditching of the counseling proposal once the "death panel" rhetoric hit, fostering the impression that the proposal was indeed up to no good.

Third, Obama's own musing in a New York Times interview about whether the decision to provide a hip replacement to someone diagnosed with cancer (in this case, his grandmother) is "a sustainable model."

Fourth, his public reflections on the high health care costs associated on average with the last six months of a person's life.

Fifth, the statements of such supporters as Todd Gitlin, whose only criticism of a speech he found otherwise inspiring was: "You can say that he's still not willing to talk to Americans straight about the need to limit high-tech medicine for the very old and very frail. Presidents won't do that."

Sixth, the administration's insistent and probably misguided attempt to portray its health care reform as cost-cutting--reduced spending on the health care of whom, exactly?

At the end of Shakespeare's Tempest, Prospero, the greatest wizard prior to Albus Dumbledore, gives up his powers and prepares to "retire me to my Milan, where / Every third thought shall be my grave." People do brood about death, quite unbidden.

When they are made to brood about it, as in the case of the new focus on end-of-life care--previously known as medical care for the very sick and elderly--they are likely to resent the intrusion. And when the substance of the intrusion is a proposal that upsets the expectations they have formed on this most difficult of topics, many will be inclined to reject it. Obama's sinking job-approval numbers among seniors and the broad decline in support for the plan likely reflect these tendencies.

Obama will not dispel the anxiety by saying the rhetoric about "death panels" would be laughable were it not so irresponsible and cynical. You disrupt the expectations of the elderly only at great political peril, and there are more such Americans every day.

Contributing editor Tod Lindberg is a research fellow at Stanford's Hoover Institution and editor of Policy Review.