Autonomy under fire in the health care debate

The recent hubbub over a supposed provision for “death panels” in the health care bill being considered by the U.S. Congress has revealed widespread misunderstanding among the American public of the purpose of advance directives for end-of-life care.

To briefly recap: Sarah Palin fired a broadside with her statement that “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.” She was apparently referring to an amendment that would insure counseling on advance directives for end-of-life decisions. And now we have mass outrage about the government putting granny to sleep.

The purpose of an advance directive is to allow an individual to make decisions, while of sound mind, about her medical care at some point in the future when she may be incapable of making a decision (e.g., because she is in a coma). Such directives commonly take two forms: Writing a living will allows an individual to specify what treatment she would and would not want given a particular scenario (e.g., “do not resuscitate”), and designating a power-of-attorney authorizes a representative (such as a spouse) to make decisions on her behalf should she be incapable. The purpose of these directives is give the patient more power in deciding her options, and they arose as part of the shift away from the medical paternalism of the past (“Doctor knows best”) toward increased patient autonomy and control of their own medical care. Advance directives have some problems, from the practical to the existentialist, but it is generally agreed that they enhance patients’ control over their own treatment. They are legal and used in all 50 U.S. states, Canada, and many other countries. You might think that a political party such as the GOP, which claims to value personal freedom, would be all for promoting advance directives.

So why the outrage over encouraging advance directives? Probably ignorance. Most protesters probably don’t understand the purpose of advance directives (which is not entirely their fault), and Palin was able to manipulate them to score political points. But the more interesting question is, if those opposed did understand advance directives but also knew where they came from, then where would they stand? Advance directives grew out of the “patients’ rights” movement, which paralleled other rights movements of the 1960s. At the risk of over-generalizing, there is likely a large overlap between those protesting the health care plan, and those who disliked such rights movements and would be happy to return to the “good old days” when doctors made all the decisions. So would they choose increased individual freedom or the comfort of paternalistic medical care? Such a choice might cause some heads to explode, creating a messy preexisting condition.

One upside to this story is that it’s put advance directives in the news, offering an opportunity to increase awareness about them among the general public. So perhaps some good will come of it.

Of course, we haven’t even mentioned the right to life or how the government would ration care differently than private insurers already do, both of which are neuroethically-related topics relevant to the health care debate. We’ll save that for another post.

Thoughts?

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2 thoughts on “Autonomy under fire in the health care debate

  1. Obama’s plans would create a wedge of distrust between provider and patient. Socialized medicine does this by rendering a doctor more concerned for saving costs for the “system” than he is for patient welfare. And while medicine includes many worthy and caring people, I’ve not known too many doctors that work for free, nor those that will fight the system if it means going broke. Over time, especially the newer ones, will be coopted and corrupted.

    Some distrust already exists on financial matters through the Byzantine and insulting medical billing practices. We all think, “Oh crap, how much is this gonna cost me,” even when we’re insured. How much worse, though, will it be when the distrust relates not to bills and paperwork but to your health. The doctor today get paid more when he tries to fix you; if anything, you have to spend some time each visit fending off his overly cautious suggestions that also happen to earn him fees. “OK. OK. Doc, I’ll get it done, next time.”

    It will be one more major destructive event in the history of liberalism if the medical profession too is ruined by destroying its essential character of doctor-patient trust by creating financial and legal mandates for doctors to harm their patients.

  2. Gidon highlights an important issue in bioethics (advance directives aka living wills) with the current health care reform debate in the United States. True, there has been wide misunderstanding that patient choice will be eroded by Obama’s proposal, and Gidon identifies this irony:

    “…if those opposed did understand advance directives but also knew where they came from, then where would they stand? Advance directives grew out of the “patients’ rights” movement, which paralleled other rights movements of the 1960s. At the risk of over-generalizing, there is likely a large overlap between those protesting the health care plan, and those who disliked such rights movements and would be happy to return to the “good old days” when doctors made all the decisions. So would they choose increased individual freedom or the comfort of paternalistic medical care?”

    To quell some of the misunderstandings, The Association of Bioethics Program Directors has put out a position statement. It’s an important read for anyone interested in the debate, as it provides education and much needed information. Mr. Roach, although your reply does not really have to do with the original post, given your clear interest in the debate I suggest you take a peek at the link.

    The statement can be found here: http://www.bioethicsdirectors.org/

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