Harvard researcher Mike Stopa, in the Boston Globe, argues that American’s concerns about bureaucratic rationing in a socialized heath system and the conflict of interest in end of life counseling sponsored by the government provider are entirely rational and legitimate.

Supporters of President Obama’s health care reform law have relentlessly derided Sarah Palin’s notion of “death panels’’ as a vulgar rhetorical technique, with no basis in reality, devised merely to scare a gullible, uneducated citizenry into rallying to repeal the law. The death panel notion persists, however, because it denotes, in a pithy way, the economic realities of scarcity inherent in nationalizing a rapidly developing, high-technology industry on which people’s lives depend in a rather immediate way. G.K. Chesterton once wrote that vulgar notions (and jokes) invariably contain a “subtle and spiritual idea.’’ The subtle and spiritual idea behind “death panels’’ is that life-prolonging medical technology is an expensive, limited commodity and if the market doesn’t determine who gets it, someone else will. …

The resistance to incorporating end-of-life planning into Medicare is based on the rational fear that such planning will be used to coax patients into forgoing life-extending technologies that Medicare administrators may deem risky, of marginal benefit, or unlikely to succeed — an estimation that could be based in part on the cost of the technology.

Moreover, the suspicion that such programmed advance planning conceals ulterior motives is exacerbated by the fact that relatively few patients will ultimately benefit from it. It is mainly of value for those who do not die suddenly, who have no trustworthy relations to maintain their power of decision, and who lose their wits a potentially long time before their death.

Opposition to government-funded end-of-life planning does not imply ignorance of the indignity or discomfort of having one more tube placed into one’s body to buy an extra few days of painful life. (Although one can imagine concluding that dignity is a highly overrated virtue when the alternative is death). But when a massive government bureaucracy, tasked with determining medical “best practices’’ and controlling costs, announces a policy that “wellness visits’’ should have us chatting with our doctors about what technologically invasive, life-extending procedures we would just as happily do without, we are not supposed to be suspicious?

Read the whole thing.

Via Theo.

Urging grandma to give up on expensive treatments and climb quietly out onto the icefloe will be funded by Medicare as the result of new regulations issued by former Harvard professor and self-proclaimed Marxist Donald Berwick.

The obvious conflict of interest involved in the same government footing the bill under a socialist health system operating a system of “end of life planning,” incentivizing physicians to encourage patients to forgo treatment and medications, was identified by Republicans, particularly Sarah Palin, and subsequent public outrage led to what became widely referred to as “death panels” being removed from the actual Obamacare bill passed by Congress.

Dr. Berwick, in fact, very much resembles death panels himself, being similarly too radical to get through the Senate, and having become Medicare Czar and Federal Health Care Rationer-in-Chief via a recess appointment.

Thus, Barack Obama demonstrates how democracy and the Constitution can be exponentially evaded. What cannot possibly be achieved through legislation can simply be decreed as a regulation by an unconfirmable recess-appointee Czar.

New York Times:

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment. …

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

While the new law does not mention advance care planning, the Obama administration has been able to achieve its policy goal through the regulation-writing process, a strategy that could become more prevalent in the next two years as the president deals with a strengthened Republican opposition in Congress. …

Several Democratic members of Congress, led by Representative Earl Blumenauer of Oregon and Senator John D. Rockefeller IV of West Virginia, had urged the administration to cover end-of-life planning as a service offered under the Medicare wellness benefit. A national organization of hospice care providers made the same recommendation.

Mr. Blumenauer, the author of the original end-of-life proposal, praised the rule as “a step in the right direction.” …

After learning of the administration’s decision, Mr. Blumenauer’s office celebrated “a quiet victory,” but urged supporters not to crow about it.

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” Mr. Blumenauer’s office said in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Moreover, the e-mail said: “We would ask that you not broadcast this accomplishment out to any of your lists, even if they are ‘supporters’ — e-mails can too easily be forwarded.”

The e-mail continued: “Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.” …

The proposal for Medicare coverage of advance care planning was omitted from the final health care bill because of the uproar over unsubstantiated claims that it would encourage euthanasia.

Sarah Palin, the 2008 Republican vice-presidential candidate, and Representative John A. Boehner of Ohio, the House Republican leader, led the criticism in the summer of 2009. Ms. Palin said “Obama’s death panel” would decide who was worthy of health care. Mr. Boehner, who is in line to become speaker, said, “This provision may start us down a treacherous path toward government-encouraged euthanasia.” Forced onto the defensive, Mr. Obama said that nothing in the bill would “pull the plug on grandma.” …

The rule was issued by Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services and a longtime advocate for better end-of-life care.

Oregon democrat Earl Blumenauer made liberals happy with a New York Times editorial calling conservative critics of democrat Health Care Reform “liars” and ridiculing the very idea that what Sarah Palin referred to on Facebook as “death panels” could possibly be found in the bill passed by the House of Representatives.

The most bizarre moment came on Aug. 7 when Sarah Palin used the term “death panels” on her Facebook page. She wrote: “The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgment of their ‘level of productivity in society,’ whether they are worthy of health care. Such a system is downright evil.”

There is, of course, nothing even remotely like this in the bill.

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The Wall Street Journal, in its lead editorial today, demonstrates rather effectively the falsity of Congressman Blumenauer’s self-proclaimed injured innocence. The editorial is specifically about those “death panels,” and explains exactly what they are, what they would do, and why they are a terrible idea.

Like most of Europe, the various health bills stipulate that Congress will arbitrarily decide how much to spend on health care for seniors every year—and then invest an unelected board with extraordinary powers to dictate what is covered and how it will be paid for. White House budget director Peter Orszag calls this Medicare commission “critical to our fiscal future” and “one of the most potent reforms.”

On that last score, he’s right. Prominent health economist Alain Enthoven has likened a global budget to “bombing from 35,000 feet, where you don’t see the faces of the people you kill.”

As envisioned by the Senate Finance Committee, the commission—all 15 members appointed by the President—would have to meet certain budget targets each year. Starting in 2015, Medicare could not grow more rapidly on a per capita basis than by a measure of inflation. After 2019, it could only grow at the same rate as GDP, plus one percentage point.

The theory is to let technocrats set Medicare payments free from political pressure, as with the military base closing commissions. But that process presented recommendations to Congress for an up-or-down vote. Here, the commission’s decisions would go into effect automatically if Congress couldn’t agree within six months on different cuts that met the same target. The board’s decisions would not be subject to ordinary notice-and-comment rule-making, or even judicial review.

Yet if the goal really is political insulation, then the Medicare Commission is off to a bad start. To avoid a senior revolt, Finance Chairman Max Baucus decided to bar his creation from reducing benefits or raising the eligibility age, which meant that it could only cut costs by tightening Medicare price controls on doctors and hospitals. Doctors and hospitals, naturally, were furious.

So the Montana Democrat bowed and carved out exemptions for such providers, along with hospices and suppliers of medical equipment. Until 2019 the commission will thus only be allowed to attack Medicare Advantage, the program that gives 10 million seniors private insurance choices, and to raise premiums for Medicare prescription drug coverage, which is run by private contractors. Notice a political pattern?

But a decade from now, such limits are off—which also happens to be roughly the time when ObamaCare’s spending explodes. The hard budget cap means there is only so much money to be divvied up for care, with no account for demographic changes, such as longer life spans, or for the increasing incidence of diabetes, heart disease and other chronic conditions.

Worse, it makes little room for medical innovations. The commission is mandated to go after “sources of excess cost growth,” meaning treatments that are too expensive or whose coverage will boost spending. If researchers find a pricey treatment for Alzheimer’s in 2020, that might be banned because it would add new costs and bust the global budget. Or it might decide that “Maybe you’re better off not having the surgery, but taking the painkiller,” as President Obama put it in June.

In other words, the Medicare commission would come to function much like the National Institute for Health and Clinical Excellence, which rations care in England. Or a similar Washington state board created in 2003 to control costs. Its handiwork isn’t pretty.

Read the whole thing.

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We already addressed the “no death panels in our bill” claim long ago, when the first wave of liberal denial crested, in this August 16th posting, which quotes this perfectly accurate analysis by Cornell Law Professor William Jacobsen.

Democrats don’t like it being called a “death panel,” but the idea all along has been that their version of health care reform would avoid public debate by passing the responsibility of meeting budgetary limitations to an unelected commission which would be empowered to ration services. Many of its decisions will inevitably deny medicines, treatments, and procedures whose absence will be the equivalent of a death sentence. Americans will die because government has foreclosed their medical options. The body making such decisions and condemning Americans to deaths which might have been prevented on monetary grounds will not be a “death panel?”

Only if you are a democrat, won’t it be.

Big one, must be a full Harvard professor.

Leftists characteristically avoid openly advocating their goals. They don’t call themselves Marxists or socialists. These days they even avoid the label of liberal, and prefer to speak of themselves as “progressives.” Their reliance on deception, their preference for seeking power not via an open fight, but rather by a gradual process of subversion, have made traditionally the favored zoological metaphors for leftists, not major predators like wolves, but small and sneaky vermin like rats or roaches. Winston Churchill once even described Lenin (being transported to Russia from Switzerland in a sealed train by Germany) as resembling a plague bacillus.

This morning, however, Maureen Dowd is a bit more denunciatory than usual, accusing Sarah Palin of turning back country Alaska major predator control tactics on Rahm Emanuel’s brother, medical ethicist Dr. Ezekiel Emanuel.

At the moment, what she wants to do is tap into her visceral talent for aerial-shooting her favorite human prey: cerebral Ivy League Democrats.

Just as she was able to stir up the mob against Barack Obama on the trail, now she is fanning the flames against another Harvard smarty-pants — Dr. Zeke Emanuel, a White House health care adviser and the older brother of Rahmbo.

She took a forum, Facebook, more commonly used by kids hooking up and cyberstalking, and with one catchy phrase, several footnotes and a zesty disregard for facts, managed to hijack the health care debate from Mr. Obama.

Sarahcuda knows, from her brush with Barry on the campaign trail, that he is vulnerable on matters that demand a visceral and muscular response rather than a logical and book-learned one. Mr. Obama was charming and informed at his town hall in Montana on Friday, but he’s going to need some sustained passion, a clear plan and a narrative as gripping as Palin’s I-see-dead-people scenario.

She has successfully caricatured the White House health care effort, making it sound like the plot of the 1976 sci-fi movie “Logan’s Run,” about a post-apocalyptic society with limited resources where you can live only until age 30, when you must take part in an extermination ceremony called “Carousel” or flee the city.

Painting the Giacometti-esque Emanuel as a creepy Dr. Death, Palin attacked him on her Facebook page a week ago, complaining that his “Orwellian thinking” could lead to a “death panel” with bureaucrats deciding whether to pull the plug on less hardy Americans.

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When democrats go ballistic like this, and pull out all the stops on denial, you can tell that someone has struck a nerve. For several days now, democrats everywhere have been screaming in pain over this one. Even my liberal classmates have been faithfully repeating the Gospel According to Talking Points Memo and Daily Kos: “Palin is lying about ‘Death Panels.'”

Was Palin lying? Let’s see.

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Sarah Palin’s Facebook entry said:

The Democrats promise that a government health care system will reduce the cost of health care, but as the economist Thomas Sowell has pointed out, government health care will not reduce the cost; it will simply refuse to pay the cost. And who will suffer the most when they ration care? The sick, the elderly, and the disabled, of course. The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

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Palin was repeating a point made in a House speech, Monday, July 27, 2009 (5:18 video), by Rep. Michelle Bachmann (R-6th district Minn.)

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Much of Michelle Bachmann’s speech consisted of her reading a July 24th column from the New York Post by Betsey McCaughey. McCaughey quoted Dr. Emanuel repeatedly:

Emanuel bluntly admits that the cuts (produced by democrat so-called health care reform) will not be pain-free. “Vague promises of savings from cutting waste, enhancing prevention and wellness, installing electronic medical records and improving quality are merely ‘lipstick’ cost control, more for show and public relations than for true change,” he wrote last year (Health Affairs Feb. 27, 2008).

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). …

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.

Many doctors are horrified by this notion; they’ll tell you that a doctor’s job is to achieve social justice one patient at a time.

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.

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).

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Cornell Law Professor William A. Jacobson observes that the argument Sarah Palin quoted from Rep. Bachman certainly is important and central to the debate of proposed health care reform.

The article in which Dr. Emanuel puts forth his approach is “Principles for Allocation of Scarce Medical Interventions,” published on January 31, 2009. A full copy is embedded below. Read it, particularly the section beginning at page 6 of the embed (page 428 in the original) at which Dr. Emanuel sets forth the principles of “The Complete Lives System.”

While Emanuel does not use the term “death panel,” Palin put that term in quotation marks to signify the concept of medical decisions based on the perceived societal worth of an individual, not literally a “death panel.” And in so doing, Palin was true to Dr. Emanuel’s concept of a system which

considers prognosis, since its aim is to achieve complete lives. A young person with a poor prognosis has had a few life-years but lacks the potential to live a complete life. Considering prognosis forestalls the concern the disproportionately large amounts of resources will be directed to young people with poor prognoses. When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable….

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most chance, whereas the youngest and oldest people get chances that are attenuated.

Put together the concepts of prognosis and age, and Dr. Emanuel’s proposal reasonably could be construed as advocating the withholding of some level of medical treatment (probably not basic care, but likely expensive advanced care) to a baby born with Down Syndrome. You may not like this implication, but it is Dr. Emanuel’s implication not Palin’s.

The next question is, whether Dr. Emanuel’s proposal bears any connection to current Democratic proposals. There is no single Democratic proposal at this point, only a series of proposals and concepts. To that extent, Palin’s comments properly are viewed as a warning shot not to move to Dr. Emanuel’s concept of health care rationing based on societal worth, rather than a critique of a specific bill ready for vote.

Certainly, no Democrat is proposing a “death panel,” or withholding care to the young or infirm. To say such a thing would be political suicide.

But one interesting concept which is central to the concepts being discussed is the creation of a panel of “experts” to make the politically unpopular decisions on allocating health care resources. In a letter to the Senate, Barack Obama expressed support for such a commission:

I am committed to working with the Congress to fully offset the cost of health care reform by reducing Medicare and Medicaid spending by another $200 to $300 billion over the next 10 years, and by enacting appropriate proposals to generate additional revenues. These savings will come not only by adopting new technologies and addressing the vastly different costs of care, but from going after the key drivers of skyrocketing health care costs, including unmanaged chronic diseases, duplicated tests, and unnecessary hospital readmissions.

To identify and achieve additional savings, I am also open to your ideas about giving special consideration to the recommendations of the Medicare Payment Advisory Commission (MedPAC), a commission created by a Republican Congress. Under this approach, MedPAC’s recommendations on cost reductions would be adopted unless opposed by a joint resolution of the Congress. This is similar to a process that has been used effectively by a commission charged with closing military bases, and could be a valuable tool to help achieve health care reform in a fiscally responsible way.

Will such a commission decide to curtail allocation of resources to those who are not deemed capable of “complete lives” based on prognosis and age, as proposed by Dr. Emanuel? There is no way to tell at this point since we do not have a final Democratic proposal, or know who would be appointed to such a commission.

Ezekiel Emanuel’s paper: Principles for Allocation of Scarce Medical Interventions