For those of us who believe that the absence of universal health care is America’s burning shame, the spectacle of opposition to Obama’s health-care plan is Alice-in-Wonderland bewildering and also enraging—but on one point the plan’s critics are absolutely correct. One of the key ideas under consideration—which can be read as expressing sympathy for limitations on end-of-life care—is morally revolting. And it’s helping to kill the plan itself.
Make no mistake about it. Determining which treatments are “cost effective” at the end of a person’s life and which are not is one of Obama’s priorities. It’s one of the principal ways he counts on saving money and making universal healthcare affordable.
This is the Big Brother nightmare of oppressive government that the shrewd propagandists on the right are always blathering on about. Except that this time, they could not be more right.
Obama told Diane Sawyer in June that government should “study and figure out what works and what doesn’t. And let’s encourage doctors and patients to get what works. Let’s discourage what doesn’t.”
Sawyer then asked him: “Will it just be encouragement? Or will there be a board making Solomonic decisions?”
Obama replied, “What I’ve suggested is—is that we have a—a commission that helps—made up of doctors, made up of experts, that helps set best—best practices.”
When Sawyer pressed him to say whether those practices would be enforced by law, he evaded the question.
This reeks of the Big Brother nightmare of oppressive government that the shrewd propagandists on the right are always blathering on about. Except that this time, they could not be more right.
Leave aside the argument for ending life when its prospects for continuing seem too painful or too hopeless. Leave it aside because this is one case where Kant’s beautiful categorical imperative—act as though your particular deeds should be a universal law—will never apply. We know that theft and murder are wrong because if they were universally committed, the world would explode in chaos. But the decision to end your life before nature wrenches it away is as rational and humane as the decision to prolong your life by whatever means necessary. Life is too specifically precious to turn its final phase into any type of universal practice, whether it’s enforced by custom or by law.
As for the argument that fruitless tests and “senseless” procedures are bankrupting the health-care system, that is an insult to the intelligence. No one knows which tests and procedures will be effective beforehand. No amount of “study” and research is going to address the particular case and the particular condition, let alone the particular, desperate, irrational will to live—which, in animal terms, is pragmatic and rational.
(And anyone who thinks that we are not all animals—even the “experts” Obama is so enamored of— must read David Rieff’s remarkable account of his mother Susan Sontag’s refusal to accept her doctors’ verdict of imminent death. The will to live does not suddenly become an error of judgment just because a “system” cannot “afford” to accommodate it, especially when the system has the means to do so.)
Most consequential of all, even if limitations were put on certain tests and procedures, the only people who would be affected by it would be the people who, presumably, are the ones meant to be rescued by the very plan that would be imposing those limitations. The financially strapped, in other words, who are the intended beneficiaries of the health care plan would be the only people forbidden access to expensive life-extending technology. The rich will always be able to afford it.
Once the technology to extend life has become available, you cannot restrict its availability. That would be like only letting some people use cell phones. Such technology is a drain on the system? Then save money elsewhere. It’s ironic that lacking the will to tax the very wealthy, some of health-care supporters in Congress now wish to save money by limiting end-of-life options to the economically burdened.
Where is Obama coming from? Why is such an apparently humane man not more strongly condemning a utilitarian initiative straight out of Victorian England? A good part of the explanation has to do with the University of Chicago Law School milieu that Obama comes out of. By far, the most influential figure in that world is Judge Richard Posner, who teaches law at Chicago and publishes streams of pompous, robotically written books that are much praised and little read.
Judge Posner is both an enthusiastic advocate of euthanasia and an energetic eugenicist. He once wrote of Oliver Wendell Holmes’ ideas about eugenics—Holmes believed that a just society “prevents continuance of the unfit”—that “we may yet find [Holmes’] enthusiasms prescient rather than depraved.”
Cass Sunstein, who is Obama’s nominee for regulatory czar, is a disciple of Posner and believes in what Time magazine describes as “the statistical practice of taking into account years of life expectancy when evaluating a regulation.” In other words, Sunstein believes that the lives of younger people have a greater value than those of the elderly. This, obviously, would have a radical bearing on end-of-life considerations.
End-of-life treatment is still under consideration and would be a tiny sliver of Obama’s health-care package. But it is a highly volatile sliver. Betsy McCaughey, who singlehandedly killed the Clintons’ health-care initiative 15 years ago with her infamous and infamously inaccurate cover story in The New Republic, claims that this small passage in the bill “would make it mandatory—absolutely require—that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner.” Not quite. But—painful as it is to concede anything to an ideological hack like McCaughey—it’s uncomfortably close.
The section, on page 425 of the bill, offers to pay once every five years for a voluntary, not mandatory, consultation with a doctor, who will not blatantly tell the patient how to end his or her life sooner, but will explain to the patient the set of options available at the end of life, including living wills, palliative care and hospice, life sustaining treatment, and all aspects of advance care planning, including, presumably, the decision to end one’s life.
The shading in of human particulars is what makes this so unsettling. A doctor guided by a panel of experts who have decided that some treatments are futile will, in subtle ways, advance that point of view. Cass Sunstein calls this “nudging,” which he characterizes as using various types of reinforcement techniques to “nudge” people’s behavior in one direction or another. An elderly or sick person would be especially vulnerable to the sophisticated nudging of an authority figure like a doctor.
Bad enough for such people who are lucky enough to be supported by family and friends. But what about the dying person who is all alone in the world and who has only the “consultant” to turn to and rely on? The heartlessness of such a scene is chilling.
Yet many liberals seem drawn to such fantasies of power and control. We live in a highly quantified society, entertained on all sides by divertissements that reduce human life to cute little anecdotes illustrating the morality of statistical, utilitarian analysis, from Malcolm Gladwell to Freakonomics and beyond.
A few weeks ago, The New York Times Magazine unfathomably ran an entire essay arguing, in effect, for a eugenic attitude toward end-of-life treatment written by Peter Singer, a Princeton University “bio-ethicist” whose views are squarely in line with those of Posner and Oliver Wendell Holmes. The essay drove the conservatives opposing Obama’s health-care plan into even greater apoplexy, as it should have. The only point on which it convinced was that euthanasia is morally acceptable only as an antidote to tenure.
One of Obama’s most alluring traits has been what some see as a literary bent that relishes complexity, irony, and even the mystery of the human personality. Let him turn toward that part of his nature and leave the sterile precincts of utilitarian social and legal theory behind. He should immediately and publicly declare his commitment to not placing economic hurdles in the way of people who want to prolong their life, or the life of their loved ones. In that way, he would take the air out of charlatans like McCaughey. And he would calm the fears of people who, far from being right-wing fanatics, are in clear-eyed possession of perhaps the only universal truth there is. No one wants to die.
Lee Siegel has written about culture and politics and is the author of three books:Falling Upwards: Essays in Defense of the Imagination; Not Remotely Controlled: Notes on Television; and, most recently,Against the Machine: Being Human in the Age of the Electronic Mob. In 2002, he received a National Magazine Award for reviews and criticism.