The Finance Committee's Continuing Good Work

by publius

I'm too busy at the moment with school starting to say what needs to be said about this:

The Senate Finance Committee will drop a controversial provision on consultations for end-of-life care from its proposed healthcare bill, its top Republican member said Thursday.

There really aren't words to describe not only how ridiculous this is, but how threatening it is to policymaking.  I've mentioned before that that the health coverage reform debate is a test of our institutions -- both political and media. 

In this instance, it's a complete failure.  A demonstrable falsehood was repeated and repeated, and it led the Committee to drop a very valuable provision that would help inform individuals -- particularly those with less resources -- about critical medical and legal issues.  The falsity and fearmongering drove the policy here.

Anyway, I'll have much more to say about all this later.  Feel free to vent in the comments.  I'll join you soon.

Comments

[Point]

As policy goes, it's a pretty minor concession compared to the overall reforms.

But as a symbol for how poisoned discourse affects policy, it's down right depressing.

[cleek]

it's all the Dem's fault for not communicating to the other members of the committee the truth of the relevant provision. if only the Dems had tried to explain to the other members that, no, the provision, which was added by Republicans, wa not meant to set up DEATH PANELS.

alas, they failed.

and the GOP remains blameless.

[John Miller]

I wouldn't worry to much about it. It will be in any final bill, because it is the right thing to do from a care and economic viewpoint. Of curse both Point and cleek are right, it is a terrible sign for the future of political debate and the GOP remains blameless.

[Wyrm]

It's a concession to minority rule. The Republicans win either way, either they are in the majority and rule like dictators, or they are in the minority and make so much noise that the Dems continue to roll over like beaten dogs rather then do what they were elected to do.

Sadly, I don't see this dynamic changing since Dems, for the most part, are either soft to the point of meekness, or completely beholden to the same folks that fund the Republicans, but do a better job of hiding it.

[tomaig]

Just curious...
I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions.

And have you read any of the stuff that Zeke Emmanuel has written? Since he's a close advisor to the POTUS on these matters, how can you howl with such outrage that the "death panels are a LIE!" when this Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society? Sounds to me like he has decided that if you have Alzheimer's then your life is not worth living and the State should not pay for anything other than to put you out of your misery.

Yet you folks are shreiking like someone just made stuff up out of whole cloth.

Are you that naive to not see where "no expensive care for non-contributing members of society" could lead?

Or is your faith in Obama so great that you are willfully blind when it comes to the realities of what he is proposing?

[fourhorsemen]

And the political message of dropping it is:

"See, the bill *did* have death panels in it, otherwise why whould they have removed the provision?"

[Point]

Actually, the more I think about, the more depressed I get.

About a couple of years ago, I went into activism of the mind that the biggest political problem facing the country wasn't a policy problem (like energy or health care), but in how we, as a country, talked about these things, in how we made the decisions in the first place. (Old story, I know...)

So I started working with a grassroots organization on getting money out of politics at the local level*. Then the focus shifted to health care -- and I supported the need for reform, so I stayed.

And I thought less about how to change the way we engage with these issues, and more about just fighting for policies with as much integrity and rationality as I could muster.

But now I'm having doubts. Don't get me wrong, I'll feel incredible pride to see health care fixed^ in this country; but I'm feeling slightly guilty at the moment about putting aside what was once at the forefront of my political consciousness.

^or at least improved by historic proportions

[Hogan]

Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society

This is the kind of claim that really should have a link to some source.

[Ben Alpers]

Sadly, I don't see this dynamic changing since Dems, for the most part, are either soft to the point of meekness, or completely beholden to the same folks that fund the Republicans, but do a better job of hiding it.

I'd go with Option Two, especially i/r/t the three Democrats doing the negotiating in the Finance Committee. I have yet to be convinced that any of the six key Senators of both parties involved in those negotiations are acting in good faith.

[Audrey]

"I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions."

Because young people get terminal diseases or accidents and die too?

Because our parents might face these decisions soon, and we're not just about ourselves?

Because the provisions were originally proposed by Republicans in prior bills, with bipartisan support, but now suddenly it's become a partisan issue?

Just a few ideas off the top of my head

[cleek]

And have you read any of the stuff that Zeke Emmanuel has written?

could you walk us through the steps where an adviser changes legislation to provide voluntary counseling, for those who want to decide for themselves what their own end-of-life directives are, into a panel where people decide who lives and who dies ?

[Phil]

I can't tell you how much it pisses me off that the same people who have been acting like a bunch of howler monkeys over a provision that needn't have resulted in anything more than the following:

DOCTOR: "Would you like to discuss a living will or extraordinary care provisions?"

PATIENT: "Nah, bro, it's all good."

. . . are the same people who have been pushing for DECADES to FORCE pregnant women seeking abortions to sit through a lecture, read a pamphlet, look at sonograms, etc., designed to dissuade them from seeking the care they want.

Can't we send these people to Antarctica or something?

[chmood]

@ tomalg:

"...[B]asically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society? Sounds to me like he has decided that if you have Alzheimer's then your life is not worth living and the State should not pay for anything other than to put you out of your misery."

Conflate much? You falsify your own "point". Basic health care is quality-of-life stuff FOR EVERYBODY. Extreme measures are bitterly painful and both emotionally and financially exhausting for families - especially in cases like dementia and coma - and is EXACTLY why living wills and end-of-life decisions are so important.

My father died almost 20 years ago. He had a living will, and did his best to make sure his doctors understood what he wanted. A proud man who always took care of himself and others, he did NOT want to be kept alive by machine; he did not want to be a vegetable; he wanted to "go when it's time". He was SO concerned about this that he insisted that I swear to him that I would "make sure" his wishes were carried out...no matter what....

This is the burden. If your father is in the shape you suggest, then you know the truth of what I'm saying; so why are you so opposed to the idea that your father should have had the right to choose what happened in such an extremity? Did he make a choice? Was it binding on the doctors? Is his current condition/situation what HE wanted?

Blaming the President for this dilemma is shockingly inappropriate (unless, of course, he barged into your father's hospital room and overrode the doctors by force of arms), and to my mind underscores the strains that afflict families at times like this.

As far as "shreiking like someone just made stuff up out of whole cloth", that would be those who oppose giving you and me reimbursement for talking to our doctors. Which, apparently, includes you.

[John Miller]

tomaig, you really should read what he has written rather than excerpts taken out of context. Would you consider it fair to say that Republicans want all African American babies to be aborted to reduce crime? After all, a major Republican did say those words.

As to why this is important, I have gone through the death of two parents and one father-in-law. In two of those cases decisions were easy because the decisions had been made in advance through consultations with the doctor. In the other it was excruciating to decide at what point to we give up. Also, without some kind of directive, a doctor is obligated to try all means at his/her disposal to keep the patient alive if there is the slightest chance for survival and recovery (as long as the money holds out).

Your comment speaks volumes about your lack of information on this issue.

[Nombrilisme Vide]

@tomaig:

I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions.

And have you read any of the stuff that Zeke Emmanuel has written? Since he's a close advisor to the POTUS on these matters, how can you howl with such outrage that the "death panels are a LIE!" when this Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society?

Three points: first, I'd be rather disinclined to presume a youthful-majority demographic for the posters here, though this may hinge on what you call "young".

Two, I'm puzzled why you feel something shouldn't be viewed as important unless one has a strongly self-interested relationship to it. Important should not mean "beneficial or detrimental to me personally".

Three, my understanding of the end-of-life counseling is not that it is the government dictating terms regarding how terminal care can be applied, but rather advising regarding legal options and assisting in specifying them. Three-A, I'd second the call for a citation to back up your paraphrase. Your inclusion of "basically" in it set off alarm bells for me, to say the least.

[Alex Russell]

Tomaig: And have you read any of the stuff that Zeke Emmanuel has written? Since he's a close advisor to the POTUS on these matters, how can you howl with such outrage that the "death panels are a LIE!" when this Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society? Sounds to me like he has decided that if you have Alzheimer's then your life is not worth living and the State should not pay for anything other than to put you out of your misery.

Yet you folks are shreiking like someone just made stuff up out of whole cloth.

In this Time Magazine piece by Michael Scherer:
http://www.time.com/time/nation/article/0,8599,1915835,00.html

Schrerer writes that "[Betsy Macaughy] quotes [Ezekiel Emanuel] discussing the denial of care for people with dementia without revealing that Emanuel only mentioned dementia in a discussion of theoretical approaches, not an endorsement of a particular policy."

It would be good if someone (here?) can track down the Emanuel piece that Macaughy was referring to, or find a link to someone who has. If it is the case that Emanuel was writing, "Theoretical ethical approaches that a society could take are a. .... b. ...., c....., d.... e.... (etc.)", and Macaughy just quoted Emanuel describing b. as if Emanuel was simply saying that b. is the necessary answer and the proper approach, then, yes, that would be just making stuff up.

[Ugh]

The falsity and fearmongering drove the policy here.

And this is different from, say, war on drugs, war on terror, cold war, vietnam, immigration, taxes, etc. etc. etc., how? Falsity and fearmongering is the business of america.

[Turbulence]

I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions.

I can afford to pay an attorney to help me and my wife set up living wills. Lots of people on Medicare can't. I think everyone should have their preferences written down so that their preferences will be honored. I mean, I'm not a child but I'm also strongly in favor of funding Child Protective Services. I'm not a veteran, but I think we should spend more on veteran's health care.

And have you read any of the stuff that Zeke Emmanuel has written? Since he's a close advisor to the POTUS on these matters, how can you howl with such outrage that the "death panels are a LIE!" when this Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society? Sounds to me like he has decided that if you have Alzheimer's then your life is not worth living and the State should not pay for anything other than to put you out of your misery.

I just read Emmanuel's Atlantic article yesterday. You know, the one where he argued passionately against making physician assisted suicide legal. So I'm really curious: what are you talking about? Can you please link to the writings that you're referring to?

[cleek]

It would be good if someone (here?) can track down the Emanuel piece that Macaughy was referring to, or find a link to someone who has.

i believe this is the one (via Armbinder.

[Marty]

"It's a concession to minority rule. The Republicans win either way, either they are in the majority and rule like dictators, or they are in the minority and make so much noise that the Dems continue to roll over like beaten dogs rather then do what they were elected to do."

I think this is probably too strong an indictment of the Dems. One of the things they promised was unprecedented transparency. This is what that transparency looks like. On both sides many of these things would have been dealt with outside the public view in the past.

[Porcupine_Pal]

With the death panels removed from the legislation, it should be easy to forge a concensus bill, yes?

[Marty]

"It would be good if someone (here?) can track down the Emanuel piece that Macaughy was referring to, or find a link to someone who has. If it is the case that Emanuel was writing, "Theoretical ethical approaches that a society could take are a. .... b. ...., c....., d.... e.... (etc.)", and Macaughy just quoted Emanuel describing b. as if Emanuel was simply saying that b. is the necessary answer and the proper approach, then, yes, that would be just making stuff up"

From cleeks link:

"Conversely, services 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."

This seems reasonably unambiguous.

[Gary Farber]

"I'm assuming most of the folks who post here are young. Why was this 'end-of-life' stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions."

It's almost as if everyone here thinks it's barely possible they might die someday.

Or could be hit by a car tomorrow.

Or might have a family member that might, someday, die.

Or has had a family member, or close friend, die, and seen what they went through.

Weird of them, isn't it?

[Hogan]

This seems reasonably unambiguous.

New grammar pet peeve: people who think "you should not be guaranteed X" is the same as "you should be denied X."

[John Miller]

Marty, note that in that article he is not endorsing that position, merely stating that as one of the positions that could be taken as opposed to everybody having access to everything under the sun. It is that typwe of taking out of context that is all too common these days.

And in an area such as this is totally inexcusable.

[Gary Farber]

"Marty, note that in that article he is not endorsing that position"

I'd second the idea, implied by cleek, of reading Ambinder's summary.

[Gary Farber]

"It is that [type] of taking out of context that is all too common these days."

Thusly.

[Awesom0]

Marty:

I direct you in the direction of James Fallows. This particular link itself probably doesn't have the information you're looking for, but it's filled with good links - including Fallow's long history of calling out McCaughey's long, long history of falsehoods and distortions.

http://jamesfallows.theatlantic.com/archives/2009/08/i_was_wrong.php

[Marty]

"Marty, note that in that article he is not endorsing that position, merely stating that as one of the positions that could be taken as opposed to everybody having access to everything under the sun. It is that typwe of taking out of context that is all too common these days."

I actually don't note that at all. It is part of a summary at the end preceded directly by:

"This civic republican or deliberative democratic conception of the good provides both procedural and substantive insights for developing a just allocation of health care resources . Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. Substantively, it suggests services that promote the continuation of the polity-those that ensure healthy future generations,ensure development of practical reasoning skills, and ensure full and active participation by citizens in public deliberations-are to be socially guaranteed as basic." (bold added)

So far today I have seen:

Can you prove it exists - yes

Was it quoted accurately - as stated yes

It is out of context - no the link was provided

The article is not endorsing that position - I read the whole thing twice, he is for the allocation of resources and this is an obvious example, I guess I just disagree that it doesn't say he is for it.

[cleek]

should you be reading, Mr Ambinder: apologies for misspelling your last name...

[dmbeaster]

This is about the unwillingness of Democrats to take on the Republican message machine. It is about the fundamental fact that the Democratic party barely stands for anything in particular, and fears a hard fight over any issue no matter how moronic. It is what caused them to lose power in 1994, and is an illness apparently still not cured.

It is worth noting that when the Republicans were in power, this is also how they got what they wanted. They threatened, lied, wnet crazy and required a sustained fight on principle in order to oppose them. That is how we ended up with so much crap, but also how Bush could continue to get his way on certain things even after 2006. How many posts were there from that era about how the Dems ran running scared when the rhetoric got tough?

It is hard to see where Obama stands on any of this, or as the 8-ball says, "Reply hazy, try again" which is better than "Better not tell you now."

[Cyrus]

Here's another link, this time with Emmanuel's recent commentary on it.

"[I] was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources ... My quotes were just being taken out of context."

That is, as far as I know, the only time he actually advocated rationing. With respect to dementia itself I agree with Hogan when he points out that the difference between "doesn't guarantee" and "denies" is big. It should be obvious to anyone approaching the issue honestly. Tomaig was, if not lying, lied to and thoughtlessly repeated it.

[Carleteon Wu]

I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? ....anyone with dementia (such as my father-in-law)

So, you get to care because of family, but you think- what, that the rest of us (youngsters all) don't have families, or just that we don't care about them?

And have you read any of the stuff that Zeke Emmanuel has written? Since he's a close advisor to the POTUS on these matters, how can you howl with such outrage that the "death panels are a LIE!" when this Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society?

Because they are not in any bill. Im not aware that anyone in Congress has proposed an amendment of this nature in good faith. Im not aware of any statements by the administration that this is a goal of theirs, or that they would even tolerate something like this.
So yes, the death panels are a lie. If I were to extrapolate from John Ashcroft and Trent Lott's footsie with Southern white supremacists into a claim that Bush wanted to reverse the results of the Civil War, it would be a similar falsehood.

Or is your faith in Obama so great that you are willfully blind when it comes to the realities of what he is proposing?

You are a liar- Obama has proposed nothing of the sort.

[Johnny Canuck]

Marty, what do you understand the phrase "socially guaranteed as basic." to mean?

[Marty]

" the difference between "doesn't guarantee" and "denies" is big"

This difference is irrelevant when we are talking about setting the level of basic healthcare that society agrees is guaranteed. The provider(or instrument of requiring delivery) of that healthcare is the government so if they don't guarantee it, it can be denied.

[cleek]

i'm still waiting for Emmanuel's attackers to explain how the bill in question sets up any kind of death panel.

Marty? wanna give it a try? you seem to think Emmanuel's essay is an endorsement of some kind of kill-the-infirm system. care to explain how that paragraph gets us from the bills we have no, to the future you imagine Emmanuel wants ?

[russell]

I've read Emmanuel's piece a couple of times now.

First, the topic he is addressing isn't specifically whether Alzheimer's patients should be denied medical care. The topic he is addressing is the fact that an inability to agree on what medical services ought to be included in any kind of universal coverage program prevents us from establishing such a program.

Further, he states that coming to such an agreement will require us to consider "the good" in a social sense. There isn't, he claims, a way to get there from here without considering questions of social value.

He suggests (not normatively, more in the sense of a prediction) that a consensual understanding of "the good" would likely, or at least possibly, not guarantee medical services to folks suffering from dementia.

A couple of observations:

First, he's only discussing what would be made available as part of socially guaranteed universal coverage. As has been pointed out upthread, "not guaranteed" is many miles away from "denied".

Second, it's unclear to me what is meant by "medical services". Does "denial of services" mean the demented would be left to utterly fend for themselves, even if they are incapable of doing so? Would they not be fed, clothed, housed, and given whatever basic palliative care is available?

Net/net, it's unclear (to me) what exactly what fate Emmanuel is envisioning for the demented, nor is it clear whether that fate is one he endorses or not.

All of that said, to be honest it's not that hard for me to extrapolate from Emmanuel's piece to a world in which Alzheimer's patients were disqualified from publicly guaranteed care. I assume that, frex, Medicare would currently cover basic medical services for senile dementia, so this could actually be a step backward for them.

That would suck.

However: I don't see anything resembling what Emmanuel describes being proposed by anybody as a matter of public policy. Not only not yet, but not bloody likely, ever.

So, yes, there is (to me at least) some troubling language in Emmanuel's piece, but in the context of the policies that are actually being proposed and the debate we're actually happening, the idea of "death panels" is paranoid hogwash.

[liberal japonicus]

"I'm assuming most of the folks who post here are young. Why was this "end-of-life" stuff so important to you? It almost seemed like you took it personally that folks opposed these alarming provisions."

Any number of people have chimed in, but let me speak from my experience. My mom passed away 2 years ago from cancer that we thought was gone. We had about 5 months to come to grips with what needed to be done and it was just my brother and me trying to wrestle with this. By the end of the 5 months, we had cobbled together a network of people who were able to address the myriad problems that we faced, but I'm still not sure if we took the best option and the time that it took was time lost. Some sort of network/system to maintain and pass on the kinds of knowledge that is hard earned in these cases matters a great deal to me, especially since my dad is here for a month for what will probably be his last visit here and we have to consider various things.

I have to admit, if I had gotten to your comment first, I would have broken posting rules pretty badly. But as it was a pro-life Republican senator, Isakson from Georgia, who put the end of life panel support into the bill, so I will assume that the problem is lack of information rather than ill intent.

[tomaig]

"[I] was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources..."

??
That sounds even worse...So if a person with dementia has viable organs that can be harvested/transplanted is that when the "no guarantees" part comes in?

Like "Live Organ Donation" from Monty Python's "The Meaning of Life" only worse because they'll have to euthanize grandma first...

[Marty]

"Marty? wanna give it a try? you seem to think Emmanuel's essay is an endorsement of some kind of kill-the-infirm system. care to explain how that paragraph gets us from the bills we have no, to the future you imagine Emmanuel wants ?"

I don't care about what Emmanuel wants. I just think he said it and everyone trying to say he didn't, or he didn't mean it, is intellectually dishonest. Just as I discount anything he said in a 2009 Lancet article as being too close to CYA for me to believe it.

People call others lots of bad names, my least favorite, by far, is liar. When asked to prove a statement and facts are supplied then the answer is you were right. Not all of us are good at that, occasionally me.

[Eric Martin]

The provider(or instrument of requiring delivery) of that healthcare is the government so if they don't guarantee it, it can be denied.

No!

The government is not the healt care provider!! Not government health care.

This is government provided INSURANCE!

The government can decline to cover certain treatments, procedures and medicine, like private insurers do as a matter of course. But that does not mean that people cannot obtain the applicable treatments, procedures and medicine. They just have to come out of pocket.

[Eric Martin]

That sounds even worse...So if a person with dementia has viable organs that can be harvested/transplanted is that when the "no guarantees" part comes in?

Whaaaaaa? That is beyond ridiculous. Trollville.

[Hogan]

The provider(or instrument of requiring delivery) of that healthcare is the government

No. Or, to put it another way, no. Not in any bill currently being considered, or at all likely to be considered in the lifetime of anyone here. The most that's being proposed by anyone in Congress or the White House is that the government become a larger financer of health care than it is now, and that it guarantee a minimum level of coverage for private and public insurance; they are not making the government the deliverer of health care, and they are not having the government set a maximum on what and how much health care you're allowed to have.

So, to sum up, no.

[hairshirthedonist]

Given this: "[I] was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources ... My quotes were just being taken out of context."

and this: With respect to dementia itself I agree with Hogan when he points out that the difference between "doesn't guarantee" and "denies" is big.

this is truly academic. I find it hard to imaging too many people even seeking organ transplants for those with dementia. And, if they do, I suppose they could have at it (under a proposed government-provided insurance regime). They'll just have to find a way to pay for it, as they probably would under our current system (if money is even the driver for obtaining replacement organs in such cases today).

I could be wrong about this, but I doubt insurance companies generally pay for such things in such cases currently. And, even if they would in theory, would those organs be made available, anyway? (Sorry for the passive voice. I'm just not sure how organs get to people now. But it seems reasonable to think there would be some non-monetary mechanism that would prioritize recipients not suffering dementia or terminally ill over recipients otherwise.)

In any case, I can't imagine many people, if any, with dementia have been getting organ transplants over, say, the last 20 years. Does anyone have an idea how to get stats on such a thing? I hate to simply rely on my general sense of things to make this kind of argument.

[Marty]

"No!

The government is not the healt care provider!! Not government health care.

This is government provided INSURANCE!

The government can decline to cover certain treatments, procedures and medicine, like private insurers do as a matter of course. But that does not mean that people cannot obtain the applicable treatments, procedures and medicine. They just have to come out of pocket."

Sorry Eric, you are correct.

[Johnny Canuck]

"But as it was a pro-life Republican senator, Isakson from Georgia, who put the end of life panel support into the bill, so I will assume that the problem is lack of information rather than ill intent."

I think this is not quite correct, Isakson has in the past proposed similar end of life counselling provisions which, ironically would have been mandatory for medicare appllicants- don't do the counselling ineligible for medicare. This provision simply provided for funding, and prior to being terminally ill, unlike the Bush era provision which only provided for it when you were terminally ill.

[Cyrus]

Whaaaaaa? That is beyond ridiculous. Trollville.

Probably. It can be hard to tell sometimes.

[Uncle Kvetch]

Whaaaaaa? That is beyond ridiculous. Trollville.

Fifty bucks says "ZOMG OBAMA WANTS TO PUT SICK OLD PEOPLE TO DEATH SO HE CAN HARVEST THEIR ORGANS!!!1!" is next week's meme.

Another fifty bucks says that by this time next week Marty will have explained to us that the widespread propagation of this meme is Obama's fault for not getting his message out clearly.

Run, Tomaig! Run and tell the people!

[cleek]

I just think he said it and everyone trying to say he didn't, or he didn't mean it, is intellectually dishonest.

the point in question was tomaig's:

"Emmanuel has stated that, basically, anyone with dementia (such as my father-in-law) should NOT receive anything more than basic care since they can never be a contributing member of society? "

and Emmanuel absolutely did not say that "anyone with dementia ... should NOT receive anything more than basic care since".

Emmanuel was talking about the kinds of things that could happen if people started thinking about health care in a certain way. his denying care example was just one of the results, in this hypothetical world. and he says he doesn't "fully defending" the resulting conclusion, but offers it as an illustration of the kinds of decisions people will have to make, if we are to have universal health care.

of course, insurance companies already make these decisions, all the time. the media is full of examples of ICs denying coverage for (from our perspective) trivial or cruel reasons. most people can tell their own stories about how their IC has denied them coverage.

intellectual honesty would demand acknowledging that we already have "death panels".

[Gary Farber]

"I direct you in the direction of James Fallows."

I got an email from him yesterday! (Okay, it was just a short "many thanks" for sending him some "great" links, and another sentence or two, but I was inordinately pleased.)

I read Fallows' blog regularly. He also followed up yesterday's post today.

"should you be reading, Mr Ambinder: apologies for misspelling your last name..."

But "Armbinder" is so much more fitting when someone writes about health care.

Besides, I bet he gets that a lot. (Oh, yes, pet peeves? "alot.")

"Three, my understanding of the end-of-life counseling is not that it is the government dictating terms regarding how terminal care can be applied, but rather advising regarding legal options and assisting in specifying them."

Actually, it's simply the government providing funds for you to consult with your doctor or lawyer (which otherwise turns out to cost money! Money you maybe can't afford, especially if you're old and ill!). How terrible this is!

Marty: "he is for the allocation of resources"

Oh, noes! I think it would be much better if we didn't allocate resources, and simply produced them infinitely! Who could disagree?

"The provider(or instrument of requiring delivery) of that healthcare is the government so if they don't guarantee it, it can be denied."

Unlike insurance companies, and HMOs, which cannot deny services!

And people without health insurance at all definitely can't be denied services, because they don't have any to start with!

It certainly would be terrible if people could be denied health services; that would be a huge change in current health care.

Observation: as is so often the case, the underlying arguments here tend to revert to variants of: "government is the [potential] problem!" "No, it isn't!" "Yes, it is!" "No, it isn't!" "Yes, it is!"

[dmbeaster]

One oddity is the failure to engage the nutball rhetoric. On some level, the theory seems to be to not legitimize it by meeting it squarely. That is sometimes true and probably the correct response to someone arguing that the Moon landings never happened. Who cares what they think and why argue with such people.

But in the health-care situation, nutball rhetoric can be an opportunity. Use it as the foil for making your own arguments -- how often does the other side give you a ready-made strawman? i.e., "this is what we want and this is the crap they say (death panels, etc.)". You can even be a little nutty yourself, and point out how they favor private death panels called insurance companies. Make the argument a contrast between clear logical specifics and nutball crazy. If you cannot win that argument, you do not deserve political leadership.

[Gary Farber]

Marty: "People call others lots of bad names, my least favorite, by far, is liar."

Marty, two sentences earlier: "I just think he said it and everyone trying to say he didn't, or he didn't mean it, is intellectually dishonest."

[Marty]

"intellectual honesty would demand acknowledging that we already have "death panels"."

The problem with this argument is that if I admit we currently have death panels then I have to concede we will have them after the reform bill passes. I would then be playing into the hands of the wingnuts that want me to admit my treachery.

[Marty]

"Marty: "People call others lots of bad names, my least favorite, by far, is liar."

Marty, two sentences earlier: "I just think he said it and everyone trying to say he didn't, or he didn't mean it, is intellectually dishonest." "

I recognized this when I wrote it, intellectual dishonesty is typically not being honest with ones self. I suspect no one here of lying to me.

[Uncle Kvetch]

It certainly would be terrible if people could be denied health services; that would be a huge change in current health care.

Precisely.

This is what has me tearing my hair out, and thinking that maybe I just need to avoid any discussion of this topic for the foreseeable future, for the sake of my own sanity. Seeing people criticizing the proposed reforms for the exact same things that are already part of the system right now...it was funny the first couple hundred times, but the utter lack of self-awareness is really starting to give me agita. The dire warnings of "big, confusing bureaucracy," "some bureaucrat making life-or-death decisions for you," "resources will have to be allocated"--what country have these people been living in? Is this all some elaborate put-on? Am I on Candid Camera?

[Gary Farber]

Conservative Republican Senator Johnny Isakson of Georgia speaks:

[...] How did this become a question of euthanasia?

I have no idea. I understand -- and you have to check this out -- I just had a phone call where someone said Sarah Palin's web site [actually, a post on her Facebook page -- definitely the place to start a policy discussion -- gf] had talked about the House bill having death panels on it where people would be euthanized. How someone could take an end of life directive or a living will as that is nuts. You're putting the authority in the individual rather than the government. I don't know how that got so mixed up.

You're saying that this is not a question of government. It's for individuals.

It empowers you to be able to make decisions at a difficult time rather than having the government making them for you.

The policy here as I understand it is that Medicare would cover a counseling session with your doctor on end-of-life options.

Correct. And it's a voluntary deal.

[...]

And the only change we'd see is that individuals would have a counseling session with their doctor?

Uh-huh. When they become eligible for Medicare.

Are there other costs? Parts of it I'm missing?

No. The problem you got is that there's so much swirling around about health care and people are taking bits and pieces out of this. This was thoroughly debated in the Senate committee. It's voluntary. Every state in America has an end of life directive or durable power of attorney provision. For the peace of mind of your children and your spouse as well as the comfort of knowing the government won't make these decisions, it's a very popular thing. Just not everybody's aware of it.

What got you interested in this subject?

I've seen the pain and suffering in families with a loved one with a traumatic brain injury or a crippling degenerative disease become incapacitated and be kept alive under very difficult circumstances when if they'd have had the chance to make the decision themself they'd have given another directive and I've seen the damage financially that's been done to families and if there's a way to prevent that by you giving advance directives it's both for the sanity of the family and what savings the family has it's the right decision, certainly more than turning it to the government or a trial lawyer.

Isakson:

[...] Political positions

Since his election to the House, Isakson has moved considerably to the right on social issues. He is now anti-abortion, anti-gay marriage and pro-gun rights. On the Issues, a nonpartisan Web site that rates candidates, labels Isakson "a libertarian-leaning conservative."[3] When he ran in the 6th District in 1999, Isakson largely ignored the issue of abortion; however, in 2003–2004, in his campaign for the Senate, he took the same position as President Bush, saying we needed to "create a culture of life" in America.[citation needed]

Isakson has been given an "A" rating by the National Rifle Association, the "Hero of the Taxpayer" award by Citizens Against Government Waste, and a "92" rating on a scale of 100 by the Christian Coalition of America (incidentally, the same score Mac Collins received). He also received a "100" rating from the American Conservative Union. National Journal recently rated him the 7th most conservative Senator in the Senate. In the Senate, Isakson is currently working to oppose the Castle-DeGette Stem Cell Bill by offering an alternative that does not allow for the destruction of a human embryo. This alternative legislation recently garnered a veto-proof 70-vote majority.

Isakson favors tougher border security to address the immigration issue[4]. He is credited for developing the "Isakson Principle," which denies the legalization of status to any illegal immigrant or the creation of a temporary worker program unless the Secretary of Homeland Security certifies ("triggers") to the president and Congress that measurable border security provisions are in place.[1] However, Isakson was criticized by advocates of immigration reduction for working on the Comprehensive Immigration Reform Act of 2007, which was criticized by some as an amnesty.[2] Contrary to his critics' assertions, Isakson only played a role in drafting the border security sections of the bill (the previously mentioned "Isakson Principle") and stated from the beginning that he was withholding his support for the bill until the final product was produced.[3] His vote of "Nay" on the final motion to end debate amounted to a vote to kill the bill.[citation needed] He and Senator Chambliss also called on President Bush to send an emergency supplemental border security spending bill to the Congress.[citation needed]

[Gary Farber]

"One oddity is the failure to engage the nutball rhetoric."

I'm not clear where you see this failure to engage; Obama has been out every day doing events denouncing the nutball stuff, and correcting the record; plenty of Democratic Representatives have been doing the same, in between being shouted at at public meetings.

[Gary Farber]

"I suspect no one here of lying to me."

But you don't think you were calling anyone a "bad name" when you said that "everyone [here] trying to say he didn't, or he didn't mean it, is intellectually dishonest"?

This is an example of what you believe is intellectual honesty?

[cleek]

The problem with this argument is that if I admit we currently have death panels then I have to concede we will have them after the reform bill passes.

we'll have fewer of them, since denial of coverage is one of the things HC reform is trying to get rid of.

[dmbeaster]

Gary:

What I mean is go after and use it directly as part of the argument. And use it in such a manner that the sound bites of the counter-argument make the news.

I agree that there is push back, but not directed at the nutball rhetoric nearly as strongly as is probably necessary. I do not pretend to know the details of the overall developments to fight back, but it seems to be more of a matter of fighting back by simply dismissing the nutball rhetoric, as in "we need not go there."

[Gary Farber]

"The dire warnings of 'big, confusing bureaucracy,' 'some bureaucrat making life-or-death decisions for you,' 'resources will have to be allocated"--what country have these people been living in?"

As I said, it just goes to people's core prejudices as to whether they believe Reagan's formula from his First Inaugural Address: "In this present crisis, government is not the solution to our problem; government is the problem," or not.

These people seem be believe, as a corallary, that big corporations, including insurance companies, are not the solution to our problem; the solution is to keep studying the problem.

Curiously, these same people tend to support/follow politicians who have among their primary financial supporters, large insurance companies and health care providers. This is all coincidence, I'm sure.

Americans have been shouting at each other variants of "government is socialism, which is totalitarianism" versus Roosevelt's -- Teddy, that is, for over a century:

[...] He brought new excitement and power to the Presidency, as he vigorously led Congress and the American public toward progressive reforms and a strong foreign policy.

He took the view that the President as a "steward of the people" should take whatever action necessary for the public good unless expressly forbidden by law or the Constitution." I did not usurp power," he wrote, "but I did greatly broaden the use of executive power."

[...]

As President, Roosevelt held the ideal that the Government should be the great arbiter of the conflicting economic forces in the Nation, especially between capital and labor, guaranteeing justice to each and dispensing favors to none.

I've given long quotes here before from this speech.

A much shorter set of quotes from that speech:

[...]

I am well aware that every upholder of privilege, every hired agent or beneficiary of the special interests, including many well-meaning parlor reformers, will denounce all this as "Socialism" or "anarchy"--the same terms they used in the past in denouncing the movements to control the railways and to control public utilities. As a matter of fact, the propositions I make constitute neither anarchy nor Socialism, but, on the contrary, a corrective to Socialism and an antidote to anarchy.

[...]

As a people we cannot afford to let any group of citizens or any individual citizen live or labor under conditions which are injurious to the common welfare. Industry, therefore, must submit to such public regulation as will make it a means of life and health, not of death or inefficiency. We must protect the crushable elements at the base of our present industrial structure.

The first charge on the industrial statesmanship of the day is to prevent human waste. The dead weight of orphanage and depleted craftsmanship, of crippled workers and workers suffering from trade diseases, of casual labor, of insecure old age, and of household depletion due to industrial conditions are, like our depleted soils, our gashed mountain-sides and flooded river bottoms, so many strains upon the National structure, draining the reserve strength of all industries and showing beyond all peradventure the public element and public concern in industrial health.

[...]

We stand for a living wage. Wages are subnormal if they fail to provide a living for those who devote their time and energy to industrial occupations. The monetary equivalent of a living wage varies according to local conditions, but must include enough to secure the elements of a normal standard of living--a standard high enough to make morality possible, to provide for education and recreation, to care for immature members of the family, to maintain the family during periods of sickness, and to permit of reasonable saving for old age.

[...]

It is abnormal for any industry to throw back upon the community the human wreckage due to its wear and tear, and the hazzards of sickness, accident, invalidism, involuntary unemployment, and old age should be provided for through insurance. This should be made a charge in whole or in part upon the industries the employer, the employee, and perhaps the people at large, to contribute severally in some degree. Wherever such standards are not met by given establishments, by given industries, are unprovided for by a legislature, or are balked by unenlightened courts, the workers are in jeopardy, the progressive employer is penalized, and the community pays a heavy cost in lessened efficiency and in misery.

[...]

No people are more vitally interested than workingmen and workingwomen in questions affecting the public health.

[...]

In the National Government one department should be intrusted with all the agencies relating to the public health, from the enforcement of the pure food law to the administration of quarantine. This department, through its special health service, would co-operate intelligently with the various State and municipal bodies established for the same end. There would be no discrimination against or for any one set of therapeutic methods, against or for any one school of medicine or system of healing [....]

Our aim is to control business, not to strangle it--and, above all, not to continue a policy of make-believe strangle toward big concerns that do evil, and constant menace toward both big and little concerns that do well. Our aim is to promote prosperity, and then see to its proper division.

[...]

The only effective way in which to regulate the trusts is through the exercise of the collective power of our people as a whole through the Governmental agencies established by the Constitution for this very purpose. Grave injustice is done by the Congress when it fails to give the National Government complete power in this matter; and still graver injustice by the federal courts when they endeavor in any way to pare down the right of the people collectively to act in this matter as they deem wise; such conduct does itself tend to cause the creation of a twilight zone in which neither the Nation nor the States have power.

But Teddy Roosevelt was doubtless a communist dupe.

[Gary Farber]

But let's go to the Bull Moose Platform, which is to say, Teddy Roosevelt's platform, of 1912:

[...] HEALTH

We favor the union of all the existing agencies of the Federal Government dealing with the public health into a single national health service without discrimination against or for any one set of therapeutic methods, school of medicine, or school of healing with such additional powers as may be necessary to enable it to perform efficiently such duties in the protection of the public from preventable diseases as may be properly undertaken by the Federal authorities, including [...] co-operation with the health activities of the various States and cities of the Nation.

[...]

The supreme duty of the Nation is the conservation of human resources through an enlightened measure of social and industrial justice. We pledge ourselves to work unceasingly in State and Nation for: [...] The protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance adapted to American use [....]

Commie, commie, commie!

We need to study these proposals longer: we can't rush into such complex issues.

[Gary Farber]

"I do not pretend to know the details of the overall developments to fight back, but it seems to be more of a matter of fighting back by simply dismissing the nutball rhetoric, as in 'we need not go there.'"

August 11th:

PORTSMOUTH, N.H. -- Hoping to blunt the momentum of critics, President Barack Obama went on the offensive in support of his health care plan Tuesday, urging the country not to listen to those who seek to "scare and mislead the American people."

"For all the scare tactics out there, what is truly scary is if we do nothing," Obama told a friendly town hall audience.

Retooling his message amid sliding support, Obama poked at critics who he said were trying to "scare the heck out of folks." He said there should be a vigorous debate over health care, but "with each other, not over each other."

"Where we disagree, let's disagree over things that are real, not these wild misrepresentations that don't bear any resemblance to anything that's actually being proposed," Obama said, trying to wrest back control over a debate at the core of his political agenda.

Addressing a town hall in New Hampshire, Obama also flayed the insurance industry in an attempt to attract a vital -- and skeptical -- audience: the tens of millions of people who already have health insurance and are just fine with the care they get.

He said the overhaul is essential to them, too, contending it is the way to keep control in their hands.

"Your health insurance will be there for you when it counts, not just when you're paying premiums," Obama said to applause at a local high school.

Obama said "after all the chatter and shouting and the noise," Americans will soon have more and cheaper options for health care.

"I don't think government bureaucrats should be meddling. But I also don't think insurance company bureaucrats should be meddling," he said.

Obama's pitch came as angry crowds have put many lawmakers on the defensive as they try to talk about health care with their constituents, leading some to replace public forums with teleconferences or step up security to keep protesters at bay.

The disturbances come at a critical time as lawmakers -- mostly Democrats -- return home for the August recess and host the meetings to boost support to overhaul the nation's costly health care system.

The president accused critics of creating "boogeymen."

"Spread the facts. Let's get this done," Obama implored the crowd.

August 9th:

President Barack Obama is warning Americans not to believe “rumors” that the health reform initiative he’s pushing will lead to a government-run health care system or push Medicare recipients to die rather than running up a hefty tab for medical services.

"Let me start by dispelling the outlandish rumors that reform will promote euthanasia, or cut Medicaid, or bring about a government takeover of health care. That's simply not true," Obama said in his weekly radio and Internet address released Saturday morning.

"This isn’t about putting government in charge of your health insurance; it’s about putting you in charge of your health insurance. Under the reforms we seek, if you like your doctor, you can keep your doctor. If you like your health care plan, you can keep your health care plan,” Obama insisted.

Obama’s message about rumermongering dovetailed with an effort that the White House launched on the Internet this week to collect and refute what Obama aides said was misinformation being spread about Democratic health reform proposals.

[...]

“As we draw close to finalizing — and passing — real health insurance reform, the defenders of the status quo and political point-scorers in Washington are growing fiercer in their opposition,” the president said. “In recent days and weeks, some have been using misleading information to defeat what they know is the best chance of reform we have ever had. That is why it is important, especially now, as senators and representatives head home and meet with their constituents, for you, the American people, to have all the facts.”

Raleigh, July 29th.

Short quote:

BRISTOL, Va. — Kroger deli worker Charlotte Norman asked President Barack Obama Wednesday if her 90-year-old mother will be “put out to pasture” and abandoned by Medicare.

“Please tell me it isn’t so,” Norman told Obama.

Norman’s question was among the concerns Obama tried to address while pitching his health care reform agenda to about 100 Kroger workers in the supermarket’s produce section during a campaign- style event.

Obama responded it wasn’t so.

“Medicare is in place, and as long as I’m there and even long after I’m gone, Medicare will continue to be in place,” Obama promised.

[...]

“Just tell your mom ‘Nobody is messin’ with her doctor,’” he told Norman. “Nobody is messin’ with her Medicare. People should not believe all this stuff they hear. ... I got this one letter from a woman. She said, ‘I don’t want government-run health care. I don’t want your socialist plan. And don’t touch my Medicare.’”

And so on.

[Benjamin]

Terri Schiavo was let go for lack of a will.
Now end-of-life counseling's also been killed.
Th' provision died
By death panel lies
Of Palin, whose brain-deadness Schiavo equaled.

[Uncle Kvetch]

As Gary demonstrates, Obama has, in fact, been doing what he can to swat down the lies.

Unfortunately, that does nothing to keep the lies from being repeated.

So then what?

[jonnybutter]

[Emmanuel is claiming that] an inability to agree on what medical services ought to be included in any kind of universal coverage program prevents us from establishing such a program...[and he states] that coming to such an agreement will require us to consider "the good" in a social sense. There isn't, he claims, a way to get there from here without considering questions of social value.

This is the nub of the whole argument (thanks russell). Emmanuel is absolute right, as summarized above. The choice is between having the arbitrary, cruel, ungodly expensive 'system' we have now, and having a rationalized system in which ethics and humanity play the central role. It is a failure of nerve, a failure of *character* to choose the former. I understand what Marty was saying before about people being scared - that, right or wrong, the fear is real. But self-confident adults understand that eventually difficult decisions have to be made, lest they be made for you - arbitrarily - by events. Self-confident nations understand that, too - great nations do.

Should organ transplants be guaranteed as a basic right for all terminal Alzheimer's patients? That is a hard question, but I do think it's at least debatable, and answering 'no' doesn't make you Megele. Until we learn how to grow kidneys in the lab, they will be in short supply, and we're going to have to decide how to deal with questions like this. I would bet my life that, overall, a government-administered health insurance regime would handle such questions more humanely - erring on the side of generosity - than would a for-profit insurance company.

The question here is: do we trust ourselves (in a democratic republic sense) enough, as humane, ethical, intelligent, competent human beings, to rationalize how we deal with public health, or do we not? If the answer is that we don't, and instead choose (accede to) chaos and entropy, we're pretty screwed - and not just vis a vis health care.

[Eric Martin]

well said jonny.

[stonetools]

The incredible thing is that we can't as a nation even get to where Teddy Roosevelt was in 1912 ( or Bismarck was a generation before that). Obama doesn't dare talk like that today, or he would for sure be labeled a commie, and there would be assassination attempts.
OTOH, maybe if he wanted out and quoted TR's words at one of these town halls,(and identified it as being from TR) it would get people to understand that advocating for national health insurance is as American as apple pie. I bet we can find some Harry Truman quotes that would be helpful too.

[Gary Farber]

"So then what?"

Death panels for critics! After we have their email addresses! But first, camps to lock them up in!

I believe Michelle Malkin has warned us of this.

Though, of course, she's also in favor of putting Americans in camps. It's all so confusing.

[Ben Alpers]

Observation: as is so often the case, the underlying arguments here tend to revert to variants of: "government is the [potential] problem!" "No, it isn't!" "Yes, it is!" "No, it isn't!" "Yes, it is!"

This is at least in part because most of the progressive organizing on this issue has been trying to get citizens to lobby Congress and the President.

It's the right that has adopted Saul Alinsky-style tactics...and they're reaping the rewards.

Proponents of real healthcare reform ought to be taking the fight to offices of major insurance companies and the homes of their CEOs, showing up with real people who've already been denied coverage, sitting in, getting arrested and getting on the news.

I'm as mad as anyone at the Democrats in Congress for blowing this issue, but their behavior has been entirely predictable. The lack of creativity in building direct actions for a grassroots pro-reform social movement is more disturbing to me. It's a sad day when progressive are even more reliant on corporate politics than the right is.

[Marty]

""I suspect no one here of lying to me."

But you don't think you were calling anyone a "bad name" when you said that "everyone [here] trying to say he didn't, or he didn't mean it, is intellectually dishonest"?

This is an example of what you believe is intellectual honesty?"

Nope, I see it as an example of how people can be ready to challenge the veracity of a statement and when proven wrong start adding a bunch of unrelated counter arguments so they don't have to say, oh yeah, you are right. I also included myself in doing that occasionally. If you are offended by th observation I will gladly apologize for the offense.

[Turbulence]

The lack of creativity in building direct actions for a grassroots pro-reform social movement is more disturbing to me. It's a sad day when progressive are even more reliant on corporate politics than the right is.

Speaking as a progressive born long after the 60s protest movements, I have trouble seeing how the kind of direct action you advocate would effect change.

I mean, let's say that a bunch of people go harass some insurance executives. And then get arrested. Why do you think the national press would cover that? I mean, when millions of people turned out to protest the war, coverage was very low. I've been trying to understand how the media works for a long time and I don't have a good enough model that would enable me to predict what sorts of direct action will reliably get the press' attention and change the dominant narrative in positive ways. Do you?

Moreover, even if direct action did get lots of press, what makes you think it would help reform? Given how many very serious people are obsessed with recasting all political disputes into a "Hippies! Fighting Squares! Free love!" narrative, it seems like direct action would hurt reform as the media used it to portray reform proponents as irrational anti-American hippies.

Part of my skepticism here comes from watching how the media reacted to Michael Moore's movie Sicko. Now, Michael Moore is fat and has various issues as a documentary maker, but it was still kind of shocking how the central story he portrayed made zero impression in the media. I'm talking about taking Americans injured on 9/11 who couldn't afford health care in the US to Cuba so they could get their damn treatment. That story shocks me. I'd think it would shock a lot of people, even if they just wanted to debunk it. But there was very little media engagement of that story; it just quietly disappeared. Here you've got real American heroes badly injured not getting the health care they need -- if the media can't get interested in a human interest story like that, I have no idea what it would take to get their attention.

[vjs]

Organ transplants are already rationed and available organs are distributed by region, health status, age, and family status. The boards that make these decisions are government-sponsored, and the decisions are outcome-based and rational, except for some of the regional discrepancies.

Organs are first made available to recipients in the same region as the donor, both for medical reasons (organs only last so long; lungs especially are fragile to transport), and 'fairness'. Organs go to people in regions where people donate organs.

My mother's transplant was determined by her age (63 at the time of surgery, 65 is the cutoff for lung transplants), family status (she had a husband and family willing to assist her in her recovery and the ongoing management of her condition), health status (she was terminal w/o the transplant), and regional (access to a hospital that performed surgeries, access to organs available in that region only). We considered moving her (you can do that to maximize your chances to get an organ--there are websites, look it up.)

My parents have good insurance that paid for this, over $250,000 for the surgery, who knows how much for the follow-up and frequent tests for rejection and lung function, >$5000/month for anti-rejection drugs alone.

Organ transplants are not the best choice for this mental exercise, as your elderly dementia patient would very likely not qualify now in any case. The fact that there will have to be some triage/rationing in any system (whether you call it 'comparative effectiveness' or whatever) is a scary one, but it's already happening, and frankly, probably should. I'd rather government/medical ethics/doctors make those decisions than insurance companies. Even if it might have denied me my mother for the last seven years, and my six year old the chance to know his Nana.

[Hartmut]

stonetools, what do you expect in a country where Bismarck can be presented as a socialist/commie without the person claiming that being laughed out of town?
Bismarck was a reactionary monarchist who nearly drove the moderate left into the arms of the (not yet called such) bolsheviks by persecuting them without mercy (and it was Wilhelm II.(!!!) who had to stop him). But I have heard/read leading right-wingers painting horror scenarios of a Bismarckian social contract taken shape in the US. Their Bismarck was somewhere to the far left of Marx.

[Jeff]

I think Marty missed a key portion of the quote -- he bolded the sentence before it, although this: Procedurally, it suggests the need for public forums to deliberate about which health services should be considered basic and should be socially guaranteed. puts the rest in context.

Emmanual is talking aboout what one such forum MIGHT decide. He goes further: A less obvious example is guaranteeing neuropsycho-logical services to ensure children with learning disabilities can read and learn to reason.

These "panels" are currently comprised of the heads of the insurance companies, and these are the kinds of decisions that they are making RIGHT NOW. Would a public forum deny more services than those currently being offered? Some how, I think not.

[Marty]

"Should organ transplants be guaranteed as a basic right for all terminal Alzheimer's patients? That is a hard question, but I do think it's at least debatable, and answering 'no' doesn't make you Megele."

A clarification, maybe,I believe that much of what Emmanuel was actually saying had merit. Also' Alzheimer's and dementia are two different afflictions.

[Hogan]

Nope, I see it as an example of how people can be ready to challenge the veracity of a statement and when proven wrong start adding a bunch of unrelated counter arguments

Tomaig was wrong. Emmanuel does not propose withholding non-basic care from people with dementia (and even if he did, that would have sweet diddly to do with currently proposed legislation). If anyone has been "proven wrong and started adding a bunch of unrelated counter arguments," it's him, and you on his behalf.

[hairshirthedonist]

Organ transplants are not the best choice for this mental exercise, as your elderly dementia patient would very likely not qualify now in any case. The fact that there will have to be some triage/rationing in any system (whether you call it 'comparative effectiveness' or whatever) is a scary one, but it's already happening, and frankly, probably should. I'd rather government/medical ethics/doctors make those decisions than insurance companies.

vjs, I don't know if your 4:38 PM comment was in response to my 1:32 PM comment, but, either way, thanks.

[Woody]

Don't get me wrong, I'll feel incredible pride to see health care fixed^ in this country

I doubt anybody here today will live to see health-care really fixed in this country, where 'fixed' means people have free access to the care they need, and the drugs they require, and the treatment necessary to full lives...

We were having just about this exact same debate 40 years ago...

[Ben Alpers]

Speaking as a progressive born long after the 60s protest movements, I have trouble seeing how the kind of direct action you advocate would effect change.

It simply cannot be any less effective than repeatedly calling the same three dozen Congresspeople or sitting around repeating facts and hoping that the media comes to give a damn.

If progressives were able to create conflict, they might be able to appeal to the media's bias in favor of it.

But I suspect you're right that it might not ultimately work. Direct action tends to work when it has teeth, when social revolution or insurrection seem a real possibility, as it did in the '30 or '60s. And that's simply not the case today.

[Rosie]

I'm a kidney transplant recipient, and I had to meet several qualifications to become eligible for the transplant program. Physically I had to demonstrate that I was healthy enough to tolerate the surgery and to sustain a transplant for a long period of time. Many tests were required--lots of blood was drawn, Xrays were taken, cardio stress tests were done, EKGs, etc. I also had a psychological evaluation and was asked questions about my social support system. I was dismayed to be told that I would have to have a diseased kidney removed to be eligible--otherwise the diseased kidney might spread infection to the transplanted organ. It took a while to make up my mind, but I gave in and had the surgery. I've known other patients who have had to have their teeth pulled because they were so infected. So you see, the awareness and cooperation of the patient are required to complete the transplant process from the very beginning. It's not just "open up the body, drop kidney in". This level of awareness would be not possible with a dementia patient. Some dialysis patients I knew (I was on dialysis for over 3 years before transplant) were denied transplants due to heart, lung, liver,etc. conditions that couldn't be reversed and would limit the lifespan of the transplanted kidney. In addition, the transplant recipient must accept responsibility for the personal care that's needed post-transplant--eating a good diet, exercise, meticulously following the prescription directions for anti-rejection drugs and putting up with their often unpleasant side effects, regular doctor visits. A high level of self-monitoring is required--again, something a dementia patient would be incapable of. Organs are not to be picked and discarded frivolously like dandelions, nor should they ever be even if they could ever be grown in a lab.

[Woody]

Organ transplants are already rationed and available organs are distributed by region, health status, age, and family status. The boards that make these decisions are government-sponsored, and the decisions are outcome-based and rational, except for some of the regional discrepancies.

I recall Mickey Mantle got a new liver, and killed it, too, just like the first one, and himself, with whiskey...

And I wondered at the time: "um, why?"

[Halteclere]

"In any case, I can't imagine many people, if any, with dementia have been getting organ transplants over, say, the last 20 years."

"Organ transplants are already rationed and available organs are distributed by region, health status, age, and family status."

My father is on a waiting list for a liver. Organ transplants, at least liver transplants, also take into account how serious the person is about taking care of themselves and their new organ. If someone refuses to stop smoking or drinking alcohol they won't get a liver.

Luckily my dad takes his health seriously and stopped drinking (it wasn't alcohol that messed up is liver - he had always been just a social drinker) as soon as his doctor began suspecting liver issues a couple years ago. But an in-laws mother who was also in need of a liver refused to gain weight (she refused to let he wait get into the triple digits) and was removed from the list.

Livers are a scare thing, and they go to 1st the person most in need, then 2nd the person most likely to live the longest with it.

[Bernard Yomtov]

Rosie,

Thanks for all that information and good luck to you.

[hilzoy]

tomaig: I bet I've read a lot more of Zeke Emanuel's writings than you have. What's being said about him is utterly, completely despicable. He's against legalizing physician-assisted suicide and euthanasia, for starters, so the very idea that he'd be involved in "death panels" is absurd. He's an oncologist who has actually spent a lot of time working with patients at the end of life, and rumor has it he's good at it.

Betsy McCaughey's article is a complete travesty. Taking her cites one by one:

First, she writes:

"Savings, he writes, will require changing how doctors think about their patients: Doctors take the Hippocratic Oath too seriously, "as an imperative to do everything for the patient regardless of the cost or effects on others" (Journal of the American Medical Association, June 18, 2008).

Yes, that's what patients want their doctors to do. But Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else."

Here's the article she's quoting. In it, Emanuel says that there are a number of reasons why health care costs too much in the US, and focuses on seven factors which, he says, drive high rates of utilization. (Together, he calls them "the perfect stprm".) Here's one:

"First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them. The thought is that the more thorough the evaluation, the more intelligent the student or house officer. Trainees who ignore the improbable "zebra" diagnoses are not deemed insightful. In medical training, meticulousness, not effectiveness, is rewarded.

This mentality carries over into practice. Peer recognition goes to the most thorough and aggressive physicians. The prudent physician is not deemed particularly competent, but rather inadequate. This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath's admonition to "use my power to help the sick to the best of my ability and judgment" as an imperative to do everything for the patient regardless of cost or effect on others."

That's where her quote comes from. But does he think that all the seven factors he discusses should be changed? No: he writes: "Some elements in the perfect storm are difficult or impossible to change; some, arguably, should not change." But wait: doesn't that mean that we can't infer that "Emanuel wants doctors to look beyond the needs of their patients and consider social justice, such as whether the money could be better spent on somebody else."? Why, yes: it does.

What Emanuel thinks we should focus on is changing the way insurance pays for services, not changing doctors' understanding of the Hippocratic Oath. Oops!

Second: "Emanuel, however, believes that "communitarianism" should guide decisions on who gets care. He says medical care should be reserved for the non-disabled, not given to those "who are irreversibly prevented from being or becoming participating citizens . . . An obvious example is not guaranteeing health services to patients with dementia" (Hastings Center Report, Nov.-Dec. '96).

Translation: Don't give much care to a grandmother with Parkinson's or a child with cerebral palsy."

This one has been discussed above. To my mind, the crucial point is that Emanuel is talking about how one might draw the distinction between (a) "basic" services, which should be guaranteed to everyone, and (b) "discretionary" services, which should not. But no one will be denied these discretionary services; they'll just have to either get a supplemental insurance policy that covers them or pay for them out of pocket.

Plus, it's not at all clear that he's advocating the line of thought he explores. But even if he were, this would not be about preventing anyone from getting care.

Third, McCaughey writes: "He explicitly defends discrimination against older patients: "Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different life stages rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years" (Lancet, Jan. 31)."

Here's the Lancet piece. Here's what Emanuel says he's talking about, near the beginning of the piece:

"Allocation of scarce medical interventions is a perennial challenge. During the 1940s, an expert committee allocated—without public input—then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria.7 During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria.7 How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested.8—12 Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multiprinciple allocation systems. We evaluate three existing systems and then recommend a new one: the complete lives system."

It's not -- not about allocating health care generally. It's about allocating scarce resources. Suppose you have only one transplantable heart, and six people who need it, and will die otherwise: who do you give it to? Should you just flip a coin? Would it matter if one of them was Hitler? Or if one was in an irreversible coma? How do you choose? -- The relevant feature of cases like this is: there are too few resources to serve everyone who needs them. Someone has to figure out who gets what, even if only by flipping a coin.

Zeke's view "prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid." And in the passage McCaughey quotes, he's saying: this is unlike discrimination on the basis of race or sex. Since race and sex are, if not impossible to change, then at any rate pretty hard to change, most people retain the race and sex they are born with for life. That means that if, say, men discriminate against women, or whites against blacks, (or vice versa), one group of people gets discriminated against for their whole lives.

Prioritizing those who have not yet lived a complete life over those who have is not like that. Everyone is an infant at some point; if you're lucky, you get to live through all the stages of a complete life. So there is not one group of people who are, say, permanently children, or permanently elderly, and who get dumped on for life.

Moreover (this is me now, not Zeke) the elderly have been lucky in that way: they have gotten to live through most of the other stages (adolescence, youth, the prime of life, etc.) Zeke's view would try to ensure that as many people as possible would get that chance.

The point he's making is conceptual: age discrimination is not like other kinds of discrimination. (Thus, there is no age version of statements like: if men menstruated ...) He's also making what seems to me the perfectly reasonable point that if you have, say, only one kidney, and you have to choose between someone who has already lived a full life and someone else who is seventeen, and if both would have a good prognosis after transplant, etc., you should give it to the seventeen year old.

The important point about this article is that Emanuel is only talking about a very small set of cases, in which you really do have to make tough choices. It is completely dishonest for anyone who has read the article to suggest that this covers all of health care. (People who haven't read the article and pass on McCaughey's claims anyways aren't dishonest, just irresponsible.)

I know Zeke Emanuel. He's not a friend, just someone I know and like. (He was the head TA in the first course I ever taught -- the one in which Andrew Sullivan was one of the other TAs. Small world.) He's a good guy and a good bioethicist. And he's about as far from "Dr. Death" as you could imagine. Plucking the odd sentence out of context to insinuate the opposite is despicable.

[hilzoy]

PS: on reflection, I don't know whether all my links will work or not -- my employer has an institutional subscription to these journals, and I don't know which are behind sub walls. However, if anyone wants a copy of any of the articles (other than the Atlantic), just email me at hbok at mac dot com, and I'll send you the pdf.

[cleek]

someone should really put hilzoy's 6:24 on the front page.

[Laura]

As awful as it is that the Dems are removing something that would be tremendously helpful to most families, what horrifies me is -- what will the GOP Senators make a bogus attack on next?

[Anonymous Coward]

"But I suspect you're right that it might not ultimately work. Direct action tends to work when it has teeth, when social revolution or insurrection seem a real possibility, as it did in the '30 or '60s. And that's simply not the case today."

Days like today are ones where I fear social revolution or insurrection are the only remaining alternatives. Everything I've seen tells me that Obama (as a politician who is trying to raise the level of debate) is well beyond what we can reasonably expect our political process to produce. If that isn't enough, I'm terrified of the conclusion I reach: the patient (i.e. the United States of America) is terminal and the only choice left is whether or not to die with dignity. I don't want to think about that, but it feels like events force me to.

Obama told the bankers: "I'm the only thing standing between you and the pitchforks." I think that's right, but I'm also sure that the people who need to understand that message don't have any conception of how right he is. Or maybe Obama is wrong and the American people no longer have the stomach to take up the pitchforks in a just and noble cause. Maybe that hypothesis is more consistent with how things have played out so far. In that case, horrible as it may seem, I suppose we deserve what we get...

[liberal japonicus]

With that last paragraph, Hilzoy performs the blog equivalent of this, albeit without Alvy Singer's neuroses.

[JanieM]

Or maybe Obama is wrong and the American people no longer have the stomach to take up the pitchforks in a just and noble cause.

"The American people" are, to understate the case laughably, not of one mind about which causes might be worthy of pitchforks.

But I'm not sure which is scarier: that "the American people" no longer have the stomach to take up the pitchforks in what *I* would consider to be just and noble causes, or that there are all too many people ready to take up the pitchforks for causes that would (from my perspective) destroy us.

[PaulW]

Question: why can't we go after the lobbyist groups financing the bussed-in rioters for fraud? These guys are trafficking in lies and rumors and no one is calling them on it. This can't be a free speech issue: they are spending money and making money, there's nothing free about it.

[John Miller]

hilzoy, I love when you are angry.

People are complaining that if everybody gets covered we won't have enough resources. Then when some actually talks about what that means and what kind of choices and decisions are going to have to be made (you know, speaking like an adult)he's the one that gets condemned.but having people speak at an adult level is apparently too much too ask.

I don't think I have ever been as disgusted by the state of discourse in this country as I am right now.

[cleek]

here's a small but hopeful sign that the media might be catching-on to the GOP's shenanigans. though it may be too late for this provision...

[brent]

why can't we go after the lobbyist groups financing the bussed-in rioters for fraud? These guys are trafficking in lies and rumors and no one is calling them on it.

Well whether or not this is entirely true, lying is not against the law and it certainly doesn't constitute fraud in a situation like this. Not by any legal theory with which I am familiar anyway.

[liberal japonicus]

This new Atlantic article may be of interest.

[Alex Russell]

*grins to see evidence that hilzoy is still alive!*

Hilzoy: Back on the 31st there was a publius post on kidney sales that spawned a 309-comment discussion in which you were very sorely missed. Late nudge?

[jonnybutter]

Obama told the bankers: "I'm the only thing standing between you and the pitchforks."

He may have said something like that, but I have my doubts; and whether he said it or not, the actual administration policy didn't really reflect that kind of statement. I think the strategy was to just save the financial industry down-and-dirty (more or less) so as not to burn through time and political capital which would be needed for all the other problems they had to deal with. That sounds reasonable, but I think it was a mistake. A larger, more durable store of political capital could've been built up by their being a little bold and administering some serious spankings. The message which was actually sent to the country was 'Yeah, 'hope' and 'change' are nice campaign words, but the reality is that quite literally business as usual continues in DC. The Big Boys get what they want.'

[Gary Farber]

Obama's stuff today, as witnessed by me via PBS Newshour, was very good, I thought.

For that matter, the rest of tonight's report was very good, as well, as is more often than not the case; this discussion of Afghanistan was informative, and so was the interview with the chair of the U.S. Space Flight Review Committee on their findings.

Not to mention Britons Take Issue With U.S. Criticism of U.K. Health System (video only).

[jonnybutter]

Obama did do quite a good job at that townhall in MT. Despite sounding tired - stumbling over words a LOT - he did as good a job as you could reasonably hope for. The guy is just really, really good.