Fearing a new, if subtle, pressure to die, the Catholic Medical Association is withholding support for proposed federal legislation promoting discussion on end-of-life options between doctors and patients.
Other groups — like the Catholic Health Association, Providence Health and Services and the National Hospice and Palliative Care Organization — are backing the idea, which is intended to improve care of the dying.
Section 1233 of the House health reform package was originally introduced in April in a bill by Rep. Earl Blumenauer, D-Ore. It would require Medicare to reimburse doctors for addressing end-of-life options with patients who are open to the conversation.
A Senate panel last week opted to drop discussions on parts of the bill that it considered too confusing or that could be misinterpreted.
The section supports discussion of options as someone draws near the end of life — living wills, health care proxies, hospice and pain medication. It also suggests talk on “the use of artificially administered nutrition and hydration.” That’s the part opponents see as a sign that elders and other patients may get undue pressure to decline such measures. The section neither promotes nor bans discussion of assisted suicide.
As written, the legislation leaves it unclear who would initiate the conversation — the doctor or the patient. That could be crucial, given elders’ deference to the opinions of physicians.
“While it is unfortunately true that physicians are paid for procedures rather than providing advice, and that in many cases people do not give adequate attention to end of life treatment decisions prior to a health crisis, the Catholic Medical Association cannot support Rep. Blumenauer’s bill as it stands — not until it is clear that such consultation would be voluntary and that other safeguards are in place to protect the elderly against pressure to forgo legitmate medical treatment and care,” says John Brehany, a medical ethicist who directs the Philadelphia-based Catholic Medical Association, a doctors’ group.
Brehany taught at Mount Angel Seminary from 1992 to 1997, just when Oregon’s debate on assisted suicide was in full tilt.
“The legal and ethical presumption in health care is to provide life-sustaining treatments unless and until they are refused,” Brehany says. “While this results in overtreatment at times, such a bill, without more adequate safeguards, could provide one-way financial incentives to persuade vulnerable elderly and ill patients to inappropriately refuse treatments far in advance of a need to address such questions.”
Two House Republicans claim the provision “may start us down a treacherous path toward government-encouraged euthanasia.”
House Republican Leader John Boehner of Ohio and Rep. Thaddeus McCotter, R-Mich., told Lifenews.com they were especially concerned about Section 1233 given that Oregon and Washington have legalized assisted suicide and a Montana court has given conditional approval.
“With three states having legalized physician-assisted suicide, this provision could create a slippery slope for a more permissive environment for euthanasia, mercy-killing and physician-assisted suicide because it does not clearly exclude counseling about the supposed benefits of killing oneself,” they say.
Blumenauer says his aim is to improve end-of-life care, promoting conversation about a topic that doctors and patients often avoid. The talks would be voluntary and could clarify what loved ones should do in a medical emergency, she says, adding that the advance consultations might also prevent patients from getting invasive procedures they don’t want.
“The provision . . . simply allows Medicare to pay for a conversation between patients and their doctors if the patient wishes to speak about his or her preferences and values,” Blumenauer said in a July 30 statement.
He was quoted Aug. 14 in the Oregonian saying he is disappointed that portion of the bill could be removed.
The lead ethicist at Providence Health and Services in Portland says that when serious illness strikes, someone other than the patient — usually the family — may be asked to make major health care decisions. Loved ones might not know what kind of care the patient wants, a source of distress, explains Father John Tuohey.
“We see this all too often when caring for our patients,” says the priest. “Formalizing a way for patients to have a voluntary discussion with their physician — and having that visit covered by Medicare — is an important step in improving advance care planning.”
Father Tuohey adds that Catholic health care guidelines encourage planning for thoughtful decisions about treatment.
“Such planning can only help bring peace, comfort and healing to patients and their families during a difficult time,” he says.
The Catholic Health Association, an alliance of health systems, has told members that the ideas in Section 1233 do not sanction euthanasia and that advance talks with doctors will be helpful.
“By reimbursing physicians for these conversations, physicians are more likely to take the time needed for a thorough discussion with their patients,” says a memo from the association. “Patients are not obliged to have such discussions with their physician, nor is there any particular course of action required of them if they do or do not.”
In addition to CHA, Providence and hospice groups, the provision is being endorsed by AARP, the American College of Physicians and the Supportive Care Coalition, a Catholic-based group formed to improve care at the end of life.
President Obama last week dismissed the critics he said are trying to “scare the heck out of folks” with “wild misrepresentations that don’t bear any resemblance to anything that’s actually being proposed.”
It would not “pull the plug on grandma because we decided that it’s too expensive to let her live anymore,” Obama said during a town hall meeting in New Hampshire.
On health care reform overall, the Catholic Medical Association is concerned that conscience rights of health-care providers are not provided for and that there is an apparent mandate to finance and provide abortion. The association is skeptical of what it calls “heavy-handed federal control” that could hurt current health insurance plans.