Over at The Gospel Coalition, I respond to Rob Moll’s controversial suggestion that Christians should endorse federal funding for end-of-life counseling.  The conclusion:

If I might close with a slightly broader point about Christian discourse on this issue, as Christians our political imagination has been stunted by our adherence to contemporary discourse. With respect to health care, the question within the last year has always been what the government should—or should not—do. If end-of-life planning for Medicare patients is a good that would ease our government’s financial burden and improve the welfare of its people, then as Christians we should spend less time being preoccupied with whether the government should pay for it and instead get down to the business of providing it.

One line that has been rolling around in my head the past few days is a modified version of 1 Corinthians 7:30, where Paul suggests we are to “mourn as if not mourning.”  In one sense, we are to die as if not dying.  How that should play out in a technocratic era is obviously a matter of some debate.

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Posted by Matthew Lee Anderson

Matthew Lee Anderson is the Founder and Lead Writer of Mere Orthodoxy. He is the author of Earthen Vessels: Why Our Bodies Matter to our Faith and The End of Our Exploring: A Book about Questioning and the Confidence of Faith. Follow him on Twitter or on Facebook.

20 Comments

  1. “Death Panels,” really? Is Mere-O that desperate for clicks?

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  2. Tim, shockingly we’re not. The phrase has reached a critical mass, I think, such that it was just easier to use as a headline than “Why Christians should oppose government funded end-of-life care per provision 1233 of the Health Care Reform bill.” : )

    I really didn’t mean anything nefarious by it. I’d love to hear your thoughts on the substance of my points, though.

    matt

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    1. Maybe it would be more helpful to put “Death Panels” in quotation marks, or say “so-called” before it? That way, we know what you’re talking about, but we don’t carry the illusion that you think the government is out to kill Grandma.

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      1. I am a devout Christian. Nothing is clearer to me, however, than that life is not unqualifiedly valuable. I suffer from migraines. The pain, before I got medicine that treated them effectively, was indescribable. I couldn’t think or even breath properly, so I used to chant to myself to help focus both things. Once, I remember, I was chanting “It will go away. It will go away.” I remember suddenly asking myself whether I would want to die if I knew it would not go away. My answer was a resounding YES!

        Extreme pain like that, really extreme pain, whether physical or emotional, is an evil. It crowds out all capacity for joy or love. It is worse than dehumanizing. It is evil. Of course none of us ever knows with certainty whether, or when such pain will cease and it is conceivable that people would choose death out of misguided pessimism. I believe, however, that the choice between life and death is one that belongs to the individual and that not only could we not deprive someone of this choice even if we wanted to, but that we must, as Christians, respect it.

        There are worse things for Christians than death. Not only is it profoundly hypocritical for us to suggest otherwise, it discredits our assertion that the true value of life transcends our earthly existence. We make ourselves a laughing stock in the eyes of Godless materialists whose fear of death is at least consistent with their metaphysics.

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  3. Mike, sorry but “death panels” communicates perfectly well what ethicists have been arguing for years. I agree with Matt that counseling by doctors and in this way should be rejected. Doctors have an immense amount of influence of persons at a vulnerable time and the conflict of interest is huge at the very least. I think there is a role for the church, but in a more comprehensive and wholistic way. The church has left death in the hands of doctors and bioethicists, and this should not be.

    Paul Griffiths has some interesting things to say on this. I think he is right to revive Ars Moriendi –there should be a Christian way of death.

    http://pauljgriffiths.com/2010/06/08/death-dying/

    http://www.baylor.edu/player/index.php?id=126004&gallery_id=5664

    But this IN NO WAY means endorsing what ObamaCare seeks to do in the “death panel” provision it keeps lying about. Embracing death at the proper time DOES NOT MEAN “hey when you’re old or disabled just cash it in,” that feeding tubes are heroic medical treatment, or that basic care may be withdrawn.

    Case-by-case on developed and understood Christian principles is the only good way. There isn’t any way to just easily check out of life in many cases. I think the church needs to lead and show how Godly people should see and practice death. Otherwise we’ll be left with a ghastly and horrible way of death.

    Here is a snippet from Griffiths from the link above: “Ambivalence is often a good thing. … To jettison the view that death is a horror to be lamented and staved off, with its concomitant that life is a good to be embraced and delighted in, easily leads to support for suicide, assisted or not, euthanasia, the refusal of medical treatment to those who might benefit from it, and all the other end-of-life unpleasantnesses that Catholic moral theologians rightly worry about.”

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  4. Christian Lawyer January 15, 2011 at 10:03 pm

    Perhaps the title should have been “Why Christians should oppose federally-funded Medicare coverage for seniors who want to consult their private physicians in order to make their own end-of-life medical decisions before a crisis hits”? Stating it this way may suggest a different answer.

    Ethically, a conflict of interest would arise only if the government had some control or influence over the doctor’s advice. Even then, it’s not a conflict for the government — it’s whether the doctor has a conflict of interest because of how the doctor is compensated. Medicare, unlike private insurance, does not reward/punish doctors based on how much is spent on a patient’s care. Thus, Medicare coverage for an office visit for seniors to consult their private doctor does not create a conflict of interest or subtle pressure on the doctor to counsel in favor of care plans that curtail end-of-life heroic medical efforts. “Rationing” is already occurring, and private insurance has taken the lead.

    Unless you have sat at the admitting station at the ER in the middle of the night and have been asked “Does your [loved one] have a living will, or a health care surrogate, or a Do Not Resusitate Order?” I don’t think you can fully appreciate how important it is for seniors to have those conversations (and make those decisions) with their physicians, with their spouses, with their kids, when they are still of sound mind, rather than having to make them (or having their children have to make them) in the middle of a crisis with a doctor they’ve never spoken to before.

    Of course Christian pastors and counselors should offer counseling on the spiritual aspect of end-of-life planning, but there are some questions and issues to which physicians can speak in more detail and with more context. Even more importantly, we as Christian kids (so to speak) should talk with our parents, offer to go to the doctor or the pastor with them. It doesn’t have to be one or the other, but going to the doctor costs significant money, especially if it’s not covered. That’s all this proposal is doing — making it slightly less difficult to have this most difficult of conversations.

    All this proposal would have done is to cover an office visit, just like any other office visit, for a senior to see their own doctor. No decisions are required, no forms are required to be checked, no “panel” is involved, and thus there can be no “panel” decision to “pull the plug.” Moreover, seniors are welcome to fire their doctor if they don’t like the advice/treatment they are getting. I helped my parents fire their doctor, and boy was he stunned. He was being paid by an insurance company through a Medicare Advantage plan, not directly by the federal government.

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  5. >> Ethically, a conflict of interest would arise only if the government had some control or influence over the doctor’s advice. Even then, it’s not a conflict for the government — it’s whether the doctor has a conflict of interest because of how the doctor is compensated.

    First, I didn’t say the conflict of interest was with the government. It matters little. The issue I’m concerned about is whether the person being consulted has best interests of the patient in mind.

    >> Of course Christian pastors and counselors should offer counseling on the spiritual aspect of end-of-life planning, but there are some questions and issues to which physicians can speak in more detail and with more context.

    I’m skeptical of this claim. I’m a philosophy student, and I had bioethics classes, and I learned so much the hard way when my father died of brain cancer. The doctors did their best, and yet there is so much they don’t tell you that I only realized on later reflection. The sort of thing that would have helped me ensure that my father was treated appropriately so as not to suffer needlessly they couldn’t tell me. I don’t really blame the doctors because it is all understandable for various reasons. But you can’t persuade me that talking doctors provide certain detail and contexts, nor that filling out forms would have helped. My experience is very much otherwise. I don’t blame them. But they are bureaucrats and act as such.

    And at some point the professionals have do admit that people generally do not have confidence in advance directives, no matter how much confidence the professionals have. The professional view seems to be that they are stupid or naive. My view is that they probably sense that they don’t do nearly as much good as the professionals say. I’m with Meilaender on durable power of attorney is a better way, and that churches could provide this for those with no family.

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  6. CL,

    Good points. Thanks for chiming in. I just want to underscore that I’m not opposed to elderly patients (or young ones!) having these conversations with doctors, though I think Mark put better my concern that we’ve outsourced these decisions to doctors and bioethicists rather than keeping them within the confines of the church. When I worked in finance, I helped several of my clients establish durable POA’s so that they would be prepared, as it’s hard to anticipate every possibility and cover it in an AD.

    I think part of the conservative concern isn’t with this provision per se, but with the trajectory that it seems to represent (especially when you consider Donald Berwick’s stated aspirations for the American medical system: http://www.realclearpolitics.com/articles/2010/11/17/meet_the_new_donald_berwick_107985.html).

    matt

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  7. >> I think part of the conservative concern isn’t with this provision per se, but with the trajectory that it seems to represent (especially when you consider Donald Berwick’s stated aspirations for the American medical system …

    Seriously. That guy was so scary to the public he was recess-appointed to avoid public questioning –an astonishingly cynical move for such a post.

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  8. Christian Lawyer January 16, 2011 at 9:49 pm

    Mark — Please accept my deepest sympathy for the loss of your father. Actually I hadn’t seen your post before I finished mine, so my comments about conflicts of interest were directed to Matt’s posting, particularly this quote in his piece at the Gospel Coalition:

    “[I]f the government is funding health care, and simultaneously funding end-of-life counseling, the government has a conflict of interest. The government has a financial incentive to encourage people to “pull the plug on granny,” regardless of whether or not that is consistent with granny’s, or her family’s, wishes.”

    >>”Doctors have an immense amount of influence of persons at a vulnerable time and the conflict of interest is huge at the very least.”

    –But, to the contrary, the counseling is precisely so seniors can consult their doctors when they are NOT vulnerable so they can make decisions calmly and not mid-crisis. A durable power of attorney gives another person decision-making power when the first person is unable to do so, but the DPOAs that I’ve seen (actually in my state they are called “health care surrogates” b/c the power is limited to health care) also lets the maker of the DPOA choose some of the types of treatment they want or do not want. That’s what they can talk to the doctor about: how do you determine that I can’t decide for myself, what does it mean when it says “no reasonable chance of recover,” will I feel pain if you withhold a feeding tube and I am terminally comatose ….

    >>The issue I’m concerned about is whether the person being consulted has best interests of the patient in mind.

    — So how does covering a counseling session cause the doctor NOT to have the patient’s best inteests in mind? Because, the issue isn’t whether the doctor can advise the patient — it’s whether the Medicare will cover it. There is NOTHING about Medicare coverage that skews the doctor’s incentives. You say that “the conflict of interest is huge at the very least,” but you don’t articulate WHAT you think the conflict is. If you’ve had to deal with private insurance, you’ll know it’s the insurance companies’ contracts with doctors that are MUCH more likely to cause a doctor to make a decision based on cost and not on what’s best for the patient.

    My legal work doesn’t involve doctors, but I do some legal malpractice cases, so I’ve had opportunity to review lawyers’ decisions that are allegedly compromised by a conflict of interest. A conflict arises when something (another client, a family member who’s paying the fees, etc.) causes a lawyer to make decisions based on what someone other than the client wants. I just don’t see how COVERAGE for the counseling causes a conflict. I’m not saying doctors are always perfectly in tune with patient’s interests. Far from it. In fact, I believe God will make a special place in hell for a few of the health care providers I fought with over my parents’ care, and for a few of the insurance and hospital bureaucrats as well. But, the question isn’t whether the doctors are perfect. It’s whether something about the coverage will skew the doctor’s advice. I just don’t see it, and respectfully, you haven’t identified it yet.

    Matt — Here’s more about Berwick: http://voices.washingtonpost.com/ezra-klein/2010/07/the_conservative_case_for_don.html

    Mark — Here’s Berwick’s own writing in which his patient-centered philosophy actually echoes what you were saying about the doctors thinking they are superior and the patients stupid and naive. Scroll down to the next-to-the-last paragraph — “What chills my bones….” http://content.healthaffairs.org/content/28/4/w555.full

    Like everything about the health care reform debate, basic facts have been completely distorted. Berwick has used proven methodologies to save lives and cut costs by making fewer mistakes and avoiding causing further harm. It’s patient-centered. If health care providers stop spreading bugs like MRSA at hospitals, patients don’t need extra days in the hospital to recover from the bug they got there. This is a good thing for both patients and hospital bottom lines. It isn’t socialism. Likewise, giving seniors access to information so that they can make their own choices is not a step on some slippery slope toward socialized medicine. It’s about empowerment and personal responsibility.

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  9. >> Please accept my deepest sympathy for the loss of your father.

    Thank you. I don’t mean to personalize it but I just wanted to say I have a bit of experience, and it has had a large effect on me. We had good doctors and I have no personal bitterness whatever, but the fact is that patients often aren’t treated as persons through no one’s direct intention. This is the way of bureaucracies.

    >> Mark — Here’s Berwick’s own writing ..

    My opposition to him is based on his own writing and interviews. You seem to think only fools would oppose him, and any quotes of his I use I’m sure you’ll pooh pooh as nothing new. How do you explain the fact that he was recess appointed with no attempt or plan for a hearing?

    Section 1233, mandating government payments for end-of-life counseling was pulled from the final health care law because it was unpopular, and then snuck back in quietly by regulatory means. Sneaky eh? Even if you are right that this is a good thing, do you really support doing things this way? I think you’ll say people don’t know what is good for them and since they don’t understand what is good for them the ends justify the means.

    >> So how does covering a counseling session cause the doctor NOT to have the patient’s best inteests in mind? Because, the issue isn’t whether the doctor can advise the patient — it’s whether the Medicare will cover it. There is NOTHING about Medicare coverage that skews the doctor’s incentives. You say that “the conflict of interest is huge at the very least,” but you don’t articulate WHAT you think the conflict is.

    How does it not? Wrong way around. The question is is that the best way to do it? Doctors have a tremendous amount of influence over patients. I’ve seen and witnessed this personally. Charles Krauthammer, a licensed psychiatrist said exactly the same thing. Like I intimated already, I learned the very hard way that doctors have a particular perspective and they are most definitely bureacrats and act as such. That is my personal observation by personal experience. They tell you what they think ought to matter to you, and this is highly influenced by what they want you to do. I know a Christian bioethicist that consults for three hospitals and he’s so convinced he’s right that he doesn’t even present opposing Christian views in his class! He won’t even tell the class “Oh and by the way, all the leading Christian bioethicists disagree with me on this one.” Most of them never learn this.

    >> If you’ve had to deal with private insurance, you’ll know it’s the insurance companies’ contracts with doctors that are MUCH more likely to cause a doctor to make a decision based on cost and not on what’s best for the patient.

    Of course. This perfectly obvious isn’t it? But why is your “oh this isn’t even the worst type” persuasive? Am I only allowed to object to the worst possible form of something?

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  10. Christian Lawyer January 17, 2011 at 11:30 pm

    Mark, I don’t say you are a fool, nor do I consider you one, for disagreeing with me about Berwick. As a lawyer, I go into court and argue against other people’s positions all the time without thinking they are all fools. But I think the totality of Berwick’s health care philosophy has been distorted. He was recess-appointed because Sarah Palin had started the “death panel” canard and the Republican minority was going to filibuster him. Recess appointments are pretty common. Pres. Bush recess-appointed John Bolton to be the U.S. Ambassador to the U.N. precisely because he knew he could never get him confirmed. I don’t think it’s the best way, but both parties do it regularly, and for important posts.

    U.S. Rep. Johnny Isakson (R-GA), who authored the original, completely non-controversial “death panel” provision, in response to a question about “how this became a question of euthanasia,” said:

    “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 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.” http://www.tnr.com/blog/the-treatment/republicans-want-kill-sarah-palins-child

    This is why the non-partisan, Pulitzer-Prize-winning PolitiFact, at the St Petersburg Times, has rated the “death panels” charge a “pants-on-fire” lie, in fact the biggest lie of 2009.

    >>How does it not [create a conflict of interest]? Wrong way around.

    –In the law, that argument is called “res ipsa loquitor” — “the thing speaks for itself.” But, that argument, since it’s not based on any logic, rarely suffices. A conflict arises from one thing acting on another. If you can’t articulate what that is, I don’t think you have much of an argument.

    I think what you are really arguing is that ALL doctor-patient relationships have an inherent imbalance of power, which is true, and so all such counseling will permit a doctor to use that power imbalance to unduly influence a patient to adopt the doctor’s recommendation. While that may be true, although good doctors work hard to guard against that, it’s a situation that exists whether OR NOT a counseling session is covered by Medicare. Thus, it’s not the coverage that causes a conflict, but the inherent power imbalance (something, BTW, that Berwick is working hard to change).

    Since the counseling is meant to take place BEFORE a crisis, the purpose is to lessen the very pressure you describe on the patients to make a less-than-fully informed decision just because it needs to be made right that minute. When no decision is necessary at all, and patients can take the forms to their pastor or lawyer or kids or guru, and mull over or pray over the decision, the immediate pressure of the doctor’s advice is actually lessened. NOT providing this coverage will likely mean continuation of the status quo, where most people wait until the crisis stage to start those conversations. At that point, the pressure to make a decision quickly can cause patients to be over-reliant on the advice of their doctor.

    As to the attempt to reinstate the provision through regulation, while that’s not the best way, it certainly wasn’t illegal or unconstitutional, unlike, say, Pres. Bush’s use of “signing statements” to essentially partially veto or ignore portions of bills he didn’t like when he couldn’t get his version of the legislation passed.

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  11. >> Berwick’s health care philosophy has been distorted. He was recess-appointed because Sarah Palin had started the “death panel” canard and the Republican minority was going to filibuster him.

    No offense Christian Lawyer, but there isn’t any point in continuing this discussion. You say you don’t think I’m a fool; I seriously doubt that since you surely think everyone else is. This is supervisory liberalism at its finest.

    BTW, you seem not to know that Obama has been using signing statements for some time now. http://www.coherentbabble.com/listBHOall.htm

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  12. Christian Lawyer January 19, 2011 at 12:51 am

    Mark — Trying to put words in my mouth (or in my heart) doesn’t really make up for not having a substantive response. A conflict of interest doesn’t exist just because you say so. What you accuse me of having in my heart isn’t there just because you say so. There’s nothing “liberal” about asking you to use your words to articulare any factual basis at all for the conflict you posited.

    BTW, even conservative law professors acknowledge that all signing statements are not alike. Nor is Obama on anywhere near the pace of Bush, who issued more signing statements than all his predecissors combined. http://volokh.com/2011/01/09/no-constitutional-signing-statement-for-the-guantanamo-transfer-restrictions/

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  13. Christian Lawyer, I used the term “conflict of interest” very loosely and not in a legal sense. That is why when you questioned me on it I immediately said “It matters little. The issue I’m concerned about is whether the person being consulted has best interests of the patient in mind.”

    So trying to pin me on a legal definition that I didn’t intend isn’t helpful. The issue I was talking about, to put the proper name on it, is paternalism.

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  14. “Set your affection upon things above.” That verse could be used to criticize any perspective on earthly matters offered by a Christian on the basis of their beliefs but it’s fair to note.

    To my mind, the apprehension that some Christians express about these so-called ‘death panels’ draws out the tension between quality of life and sanctity of life inherent in Christian beliefs. Who is the Christian to judge the quality of their God-given life and at what point the diminished quality of it allows that its sanctity may be better preserved by ending it?

    And who is the U.S. government to provide funding that they may seek this end-of-life counseling from their doctor and be forced to face this dilemma inherent in their beliefs?

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    1. REVISION: …its sanctity may be better served by allowing it to end?

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  15. >> To my mind, the apprehension that some Christians express about these so-called ‘death panels’ draws out the tension between quality of life and sanctity of life inherent in Christian beliefs. Who is the Christian to judge the quality of their God-given life and at what point the diminished quality of it allows that its sanctity may be better preserved by ending it?

    I think you are dead-on that quality of life ethics is the real issue. But I would only point out that this is by NO means a Christian issue. People who have traditional respects for life all think this way. Heroic measures to support life are not required and can be burdensome, but deciding at what point to withdraw even hydration and nutrition based on cognitive ability I think crosses the line.

    And people that don’t think Berwick and Ezekial Emmanuel are heading this direction are naive and/or haven’t read their public statements. Whether or not “death panel” applies now, anyone with sense think they will get there in a couple of steps if not, and that they do desire to get there in any case.

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  16. Agreed, that it is not a Christian issue in any particular sense but it is not wrong for it to be approached as such. I was thinking out loud about the entailments of doing that.

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  17. Thanks for this post. Obviously the post was short and to the point, and this I would expect from any believer who had thought even a moment about such topics. Historically, Christianity has been against these concepts, and will remain so as long as orthodox believers are on this green Earth. As far as the affect of contemporary discourse on contemporary Christian politics, I must agree completely; how often well intentioned believers have forsaken service to God though the use of their minds, simply because they’ve been bought with slogan and motto.

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