When taxpayers provide only a finite number of acute care beds in public hospitals, a patient whose life has all but ended, but whose family insists on keeping her on life support, is occupying precious space that might otherwise house a patient whose best years are still ahead […]Modern medicine increasingly allows us to extend life indefinitely, and so the question is no longer whether we can “play God,” but when, how, and who should do so. When humanity demands haste, and justice demands expert knowledge, Ontario’s death panels offer a solution—whatever Sarah Palin says.
What happens in Ontario might not seem immediately relevant to the US, but the problem of resource scarcity that Goldenberg builds his case upon will increasingly plague American health care. The aging of the boomers combined with expanding access to health care (through the ACA) will put more pressure on an already stressed system. Luckily there is lots that can be done to ease this pressure, including reforming service delivery, expanding the pool of competent end of life caregivers by giving nurse practitioners more autonomy, and expanding hospice programs.That is, instead of pivoting right to rationing, something the American public is unlikely to look favorably upon, we can work on rationalizing the health care system. We’ll still have to have a national conversation about if and how to ration at some point, but there’s plenty to do in the meantime.If and when that conversation does happen, however, there are some general principles that should guide it. In the Mead family, we recently went through the kind of harrowing end of life decision making that often comes as the life of a loved one comes to a close. Fortunately for us all, my mother gave us explicit guidance about how she wanted these decisions to be made. If additional medical treatment, even aggressive treatment, offered a reasonable prospect for recovery, she was willing to give it a try. But if medicine offered no real hope, then she wanted to spend her remaining time without painful and intrusive medical treatments as nature took its course. If she was unable to make this decision for herself, she named the person she trusted to carry out her wishes. When the time came, we did as she had asked, and both the family and the medical professionals respected my mother’s wishes.The end of life often comes amid confusion and uncertainty. Some choices are harder than others and whatever formal system the country adopts will not provide neat and clean answers in every situation that comes up. But this does not mean that a rigid system of bureaucratic death panels is going to be needed. Few of us really want to end up with breathing tubes down our throats, summoned heroically back from the margin of death by repeated aggressive and heroic efforts, when all hope of recovery is lost.The best answer for most end of life questions isn’t about health care rationing or bureaucratic mechanisms whatever they are called. If most Americans are mature and responsible citizens who reflect thoughtfully and carefully on the questions surrounding end of life treatment, most of the time patients and their families will make sound decisions. If we don’t have that kind of society, then neither life itself nor the end of life will be very wisely arranged.How we deal with the end of life is more a test of character than a test of bureaucracy. The effort to empower a bureaucracy to make decisions that Americans (or Canadians) can’t or won’t make on their own may be necessary under certain circumstances. The frequent resort to such a system would, however, be a sign of a profound and serious social weakness whose consequences will be felt in many ways.[Glove image courtesy of Shutterstock]