Printed in the Iowa City Press-Citizen, Aug. 15, 2009.
We understand how the pressure is on Iowa Sen. Chuck Grassley to appease his Republican base. And we can excuse those occasional misstatements that happen when the national media pay close attention to your every word. But we're at a loss over how Iowa's senior senator -- and the ranking member of the Senate Finance Committee -- stoked irrational fears this week about a provision for "advance care planning consultation" in the House version of the health care overhaul bill.
"There is some fear because in the House bill, there is counseling for end of life. And from that standpoint, you have every right to fear," Grassley said during an outdoor meeting Wednesday. "You shouldn't have counseling at the end of life. You ought to have counseling 20 years before you're going to die. You ought to plan these things out."
One could assume Grassley was just being overly empathetic. Maybe he was just telling the crowd that he understood their fears about all the misinformation and negative hoopla surrounding a provision in the House bill that would pay for patients to be able to sit down with a doctor and talk about what they want for their end-of-life care. Maybe Grassley was trying to dispel the rumors -- like President Obama tried to do earlier in the week in New Hampshire -- and he just got carried away with his "aw shucks" rhetoric.
But then Grassley said, "And I don't have any problem with things like living wills. But they ought to be done within the family. We should not have a government program that determines if you're going to pull the plug on Grandma."
What Grassley says is true: No one wants want a government program to determine when people should die. But Grassley also knows that there is no such provision in the House bill. And he also knows that reform opponents have taken the provision for voluntary "advance care planning consultation" and transmogrified it into having a panel of bloodless government bureaucrats decide who lives and who dies.
If he was trying to alleviate his audience's fears, he failed miserably. Instead, he stoked those fears to become even hotter.
Discussing end-of-life care
Talking about end-of-life care is a subject that most people already find scary enough. We fear that the media firestorm around this non-existent "death panels" not only will distract people from a rational discussion of long-need health care reform, but will also scare people further away from taking the steps necessary to make sure their family and their doctor know their preferences for end-of-life care.
If people don't prepare some form of advanced care directive, then their family members are left trying to figure out what their wishes would have been. If those family members disagree passionately enough, then the courts are left to decide.
Indeed, if the media circus surrounding the Terri Schiavo case in 2005 had any positive consequences, it was to get family members talking with each other about what type of medical intervention they would consider essential -- a feeding tube, a breathing apparatus, etc. -- and at what point they would just like to let go.
Such discussions are not merely theoretical. The only thing each of us knows for certain is that we are going to die one day. If that death comes quickly, no decision needs to be made. If it is prolonged, however, then the situation can become overwhelmingly complicated.
Avoiding a family, legal meltdown
Iowa law sets up a process that allows for the withholding or withdrawing of life-sustaining procedures if a doctor agrees with the person who has been appointed to make decision for the individual. If there is no one appointed, the law basically sets up a hierarchy of individuals who can consult and agree with a physician: The appointed proxy, the incapacitated person's guardian, the person's spouse, a majority of the person's adult children, the person's parents and then the person's adult siblings.
If discussions about end-of-life care can be done when everyone is lucid and able to think rationally -- albeit the discussions themselves can often get emotional -- then they save everyone pain and anguish at a time when few are able to think rationally.
Government has an interest in encouraging such decisions to be made ahead of time. And the House bill simply provides for people who voluntarily want to have such a discussion with a qualified physician or nurse practitioner.
Grassley is right in that the most important part of this process is for family members to talk with each other about these decisions. Because people change their minds about what counts as appropriate life-saving measures -- a healthy 35-year-old will view these issues differently when she becomes a chronically ill 75-year-old -- it's important that these discussions happen on a regular basis.
Hopefully those discussions will continue despite Grassley's ill-chosen words.