How End-of-Life Issues Are Being Used to Thwart Health Care Reform

For the past several months, as I have worked on writing a book about death, dying, and grief, I have kept my ear to the Aid in Dying movement in the United States, listening in on both advocates and their “pro-life” opponents. I’d come to suspect that end-of-life issues would be a major hurdle to health care reform. Today, unfortunately, I am closer to being right.

Since House Minority Leader John Boehner (R-OH) released a statement on Friday accusing the health care reform bill of leading America down “a treacherous path toward government-encouraged euthanasia,” opponents of the bill have seized on the aspects of the bill that concern end-of-life choice as the great obstacle to the bill’s passage. Although the leap from aid in dying to “euthanasia” or even “assisted suicide” is patently false, and entirely misleading, everyone from Fox News to the New York Post, are scaring the elderly with threats of denied service and coerced assisted suicide.

Boehner’s statement came at the end of a difficult week for the Obama administration: Obama’s poll numbers dropped notably; his health care road show received mixed reviews; and the administration was called out for lack of transparency regarding health care industry meetings. The media meme of the week, as House and Senate recess loomed, was no momentum. That Boehner chose Friday for the release, on the heels of all this successful stalling and as the five-day media cycle distractedly wandered off into the summer Friday afternoon, hardly mattered to the other “right-to-life” advocates, those concerned about the proliferation of assisted suicide in the United States.

“Pro-Life” Expands Its Reach

Increasingly, opponents of end-of-life choice have succeeded in inserting the fourth issue of the pro-life platform (abortion, stem-cell research, and cloning being the other three) into the national debate. While abortion issues will most likely remain the rallying point, and cloning and stem-cell research (Obama lifted the ban on the latter in February) have garnered little public interest, the bogeyman of euthanasia is proving to be a subject of greater use as Republicans work to frame their resistance to health care reform.

In part this is due to advocates and opponents successfully styling their efforts after their counterparts in the abortion conflict: privacy, “end of life choices,” and access to information have become the cause of assisted suicide proponents; their opponents have worked from the same “pro-life” institutions, language, and methodologies that were organized to protest abortion. With one significant new adjustment: Pro-lifers are now forced to argue for sanctity of the patient-doctor relationship and not, as with abortion, for government regulation of access to services.

In February, the New York Times Magazine featured an interview with President Obama that was immediately abstracted by groups opposed to aid in dying and circulated throughout the internet with the title “Obama: Euthanasia of the Elderly May be Necessary.” In the excerpt, Obama states, “Now, I actually think that the tougher issue around medical care… is what you do around things like end-of-life care.” Interviewer David Leonhardt interjects, “Yes, where it’s $20,000 for an extra week of life.” Obama recounts the decision his family faced when his grandmother fell and broke her hip a few weeks after being diagnosed with terminal cancer. She and the family decided that, that despite the risks of a replacement, she would “waste away” without it, immobilized, and suffer a decreased “quality of life.” Two weeks after the operation, her health further deteriorated and she soon died.

Obama continues:

So that’s where I think you just get into some very different moral issues. But that’s also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out there.

Obama’s comments acknowledge the inequality of our current system which, unethically, encourages those with health insurance to avail themselves of all available treatments. The insurance and care companies reap the profits and no one need watch the purse strings. Quality of life justifies this manner of operating—until we consider 40 million uninsured Americans who have limited quality of life services.

Charles Krauthammer, a columnist for the Washington Post, wrote a column the following Friday eviscerating Obama’s comments as indicative of a government plan to limit access to services for the sake of cost savings. “Why do you think the stimulus package pours $1.1 billion into medical ‘comparative effectiveness research’? It is the perfect setup for rationing,” he writes. “Once you establish what is ‘best practice’ for expensive operations, medical tests, and aggressive therapies, you’ve laid the premise for funding some and denying others.” Never mind that medical services are already grossly rationed. By class.

Krauthammer, and every Republican to comment on health care reform, is lifting rationing directly from talking points devised by Frank Luntz, the master spin doctor who created the term “death tax” and guided Republicans to a victory over Hillary Clinton’s health care plan 16 years ago. Other advice from Luntz? Emphasize the fatal dangers of bureaucrats determining who will receive services. Though he’s not explicit, bureaucratic rationing implies connotations of euthanasia: what the Nazis perfected on Jews in the Holocaust, or what government municipalities inflict on stray dogs.

Aid in dying is currently legal in three states: Oregon adopted the Death with Dignity Act (on which other states have modeled their subsequent bills) in 1994; Washington adopted the Washington Initiative 1000 in 2008; Montana, by court order, legalized aid in dying in December 2008. Despite being legal, end-of-life choice is still a contested right in these states. Doctor compliance is limited and the laws have extensive restrictions and requirements including psychiatric evaluation, a diagnosed life span of less than six months, and second opinion.

Nonetheless, the death with dignity movement has gained momentum as the population has grown older and advocacy organizations have become more savvy. Final Exit boasts more than 3,000 paying members and Compassion & Choices has offices in 38 states. In May 2009, the first death under Washington’s law was reported, and more than 100 legislative bills have been introduced in 24 states since Oregon’s legalization. As well, the strength of the aid in dying movement in other countries (notably England, Belgium, and Switzerland) has bolstered activists here. Public opinion on end-of-life choice is being tested in Georgia: in March, an undercover investigator lured Final Exit advocates into his home, claiming he wished to kill himself. They were arrested by local authorities and the case is pending hearing. A sentence of five years in jail accompanies conviction of assisting suicide in the state of Georgia.

Aid in dying advocates have not only been active proponents of state legislation; they have also resorted to petitioning national and federal courts. For the most part they were unfettered by the Bush administration. In fall 2004, the Florida Supreme Court ruled unconstitutional Terri’s Law, a hastily signed and highly publicized law designed to keep Terri Schiavo, a patient in persistent vegetative state for 14 years, on artificial sustenance against the wishes of her husband. The next year, in the midst of a media storm, the US Supreme Court refused to hear the Schiavo case, allowing for the removal of her feeding and hydration tubes. Despite extensive last-minute efforts, the Bush administration was unable to prevent her death by dehydration on March 31, 2005.

Later in 2005, Attorney General John Ashcroft issued a directive that banned drugs typically used for aid in dying in order to challenge Oregon’s law. But the US Supreme Court deemed the directive a violation of privacy. Alaska, Florida, Hawaii, Montana, and California all have right to privacy provisions in their state constitutions, and aid-in-dying advocates have successfully focused on producing legislature in these states. They found additional success in December 2008, when Baxter v. Montana legalized aid-in-dying in Montana. The case is being challenged by the state attorney general and is of particular concern to those opposed to assisted suicide; while Oregon and Washington laws include a conscience clause that permits doctors to refuse to participate, the Montana law does not. As Dobson noted on his radio show, requiring doctors to administer lethal drugs will push Christian practitioners out of the medical professions, thereby limiting choice for Christian patients. Or for patients who don’t wish to be cared for by a doctor “who kills people.”

A Duty to Stay Alive

A study published in the March issue of The Journal of the American Medical Association found that religious cancer patients were three times more inclined to seek extensive medical treatment in the last week of life than were non-religious patients. These decisions, the study notes, greatly increase medical fees and often prolong the suffering of the patient and their family. “To religious people, life is sacred and sanctified,” Dr. Prigerson, the study’s lead writer said, “and there’s a sense they feel it’s their duty and obligation to stay alive as long as possible.”

As Garret Keizer writes in his 2005 article for Harper’s, “Life Everlasting: The Religious Right and the Right to Die,”

…the fear of playing God operates exclusively on one side of the medical playground. Thus to help a patient end his or her life ‘prematurely’ is playing God while extending it in ways and under conditions that no God lacking horns and a cloven hoof could ever have intended is the mandate of ‘our Judeo-Christian heritage’ and the Hippocratic oath.

Where voters—and politicians—line up on this medical playground is becoming increasingly more difficult to predict.

The occasionally astute Democratic strategist James Carville was asked by Leonard Lopate in May what finally caused the public to begin critical examination of the Bush administration. Carville replied with three points, two common to the media’s analysis of Bush’s decrease in popularity: the Iraq War and Hurricane Katrina. Carville’s third point was more surprising: Terri Schiavo. “One of the most,” and here he paused, searching for the right word, “uncommented on thing[s] was this Terri Schiavo thing. It really turned a lot.”

Perhaps Boehner and his Republican colleagues learned a lesson in 2005 when they tried to insert themselves into the Schiavo family’s private grapple with faith and end-of-life issues. (If the public remembers the Schiavo issue as partisan, RNC Chairman Michael Steele’s comment, also on Friday, that Obama’s health care reform will “make the Terri Schiavo case look like a walk in the park” contradicts current Republican framing of health care reform.) Perhaps they were emboldened by the week’s developments and the recent prediction that health care reform will be Obama’s Waterloo. Or maybe the Republicans have been so decimated by this administration’s successes since November that they feel the need, in order to slow down health care reform, to employ every tool in the box.

Regardless, Boehner found it necessary to confirm his commitment to the pro-life, anti-choice faction of the Republican base. Just not during the primetime news cycle.

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