Friday, August 21, 2009

Betsy McCaughey on the Daily Show

Rachel Maddow has been saying for at least two weeks that Betsy McCaughey is the originator of what has become the death panel meme. Politifact.com rates her original statement with their flaming "pants-on-fire" rating--apparently there's a difference between a statement being just false, or flagrantly false, in their estimation.

Last night Jon Stewart's interview of Betsy McCaughey was equal parts maddening and enlightening. The Daily Show cut off the interview when they ran out of time, but the uncut version is below (in two parts).

The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 1
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The Daily Show With Jon StewartMon - Thurs 11p / 10c
Exclusive - Betsy McCaughey Extended Interview Pt. 2
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Daily Show
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Political HumorHealthcare Protests


Note that Jon makes my point about epistemic trust. The issue is less about the actual wording of the bill than it is about the presumptions that control the interpretation of the wording of the bill. At issue: do you assume that the people writing health care reform bills are trying to reform health care, i.e. extend and improve access to health care for the citizens of this country, or, do you assume, like Betsy McCaughey, that this health care bill is a "Trojan Horse" for the nefarious intent to deny access to health care for those who now have it?

Unfortunately, though Stewart did ask "do you really distrust doctors that much?" to which McCaughey answered, "I distrust politicians"--he didn't follow up much further. Cynicism about politics I get. But surely it's not in the self-interest of career politicians to make nefarious plans to kill off their constituents--so how, even in the twisted worldview of those who believe human beings only ever act in intelligent and ruthless self-interest--how does it make any sense at all to assume that the writers of HR 3200 want to kill old people?

Regardless, there are two points of McCaughey's regarding the content of the bill that I want to respond to. First, she indicates more than once that there is a long list of specified interventions that the bill mandates that your doctor try to talk you out of. Here is the part of section 1233 I think she is referring to:

‘(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items—

‘(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;

‘(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting;

‘(iii) the use of antibiotics; and

‘(iv) the use of artificially administered nutrition and hydration.’
.

Of course, there are other issues about whether this is "mandated" (I don't see that it is, and her arguments regarding indirect financial incentivizing seem a little stretched to me), and whether or not your doc is asking what you want versus talking you out of interventions (again, that trust thing. If you're that scared of your doctor, I suggest you find a new one). But on the single point of whether a bullet list of four item introduced with the phrase "may include indications respecting, among other items" constitutes a long list of specified interventions your doc must address? I don't see it. "May" still, I believe, remains a modal auxiliary verb indicating, among other things, permissibility, but not obligation (that would be "must"). I suppose though, like the word "mandatory," someone who's got skillz in reading this stuff can see where those words are crammed into the invisible subtext even when they're not there. (Ah, but that's that trust thing again.)

The second point she makes that I want to take issue with is that doctors will somehow be financially penalized if their patients don't adhere to the advance directives they create in consultation with their doctor, thus creating a situation in which people can't change their minds later if they want to. Leaving aside the discussion about financial incentivizing--which Stewart challenges her on--if her concern truly is to provide for a situation in which someone might change their mind about their advance directive, the bill itself provides for this:

‘(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.'


So there's no sense in which you only get one shot at making an advance directive, after consultation with your doctor which you don't have to pay for out of your pocket--paragraph 1 provides you can revisit this in any case every five years, but the paragraph above specifies that you can revisit your advance directive, in consultation with your doctor, more often in the event of getting terminally ill. So the scenario she paints, of your doctor collaborating with the evil politicians to talk you out of life-sustaining measures which you then cannot change your mind about later, is the opposite of what this bill actually says. Further, if you buy her financial incentivizing bit, you might could even argue that doctors have an incentive to revisit this issue with you at least every five years, and more often in the case of your getting terminally ill in some way. (But, you might not want to argue that to Betsy McCaughey; she would probably take it as further evidence that your doctor's being bribed by your government to kill you.)



P.S. I really hate the way she mugs for the camera.

6 comments:

Karen Luttrell said...

I don't think her argument is about greedy docs or politicians who want to kill you. It is about priorities. Under a universal health plan, extending life as long as the patient desires will compete with efforts to manage healthcare costs. That means rationing to some extent. That's not necessarily bad if you consider that healthcare is currently profit driven - people are give more tests than they need. I'm not saying there doesn't need to be reform, but I'm really tired of the Left skewering anyone who dares to raise concerns about the House's 1000 page juggernaut.

You should read Charles Krauthammer's latest piece cutting through all the "death panel" hyperbole. In it, he discusses that living wills are really irrelevant for most people, because you really don't know what you want until you're facing death. I think the design of this aspect of the bill is to consider quality of life and quantity. If you have could have 1 year left on a morphine drip or two years throwing up and weak from chemo, which would you choose?But do you want a bureaucrat putting his two cents in along with counseling from your doctor? Fact is, hospice and palliative care is cheaper than chemo/radiation trials and surgeries. But the House uses a sledgehammer, instead of pairing knife to explain this.

However, the "Trojan Horse" theory is not entirely without merit. Consider the recent reactivation of "Your Life, Your Choices" over at the VA. This is great example of bureaucrats trying to justify their jobs through confusing mandates. http://online.wsj.com/article/SB10001424052970204683204574358590107981718.html. If you want some idea of how gov't may manage healthcare under a universal health system, read up on the VA. It ain't pretty.

But I'm a little confused as to why this is relevant considering, I believe, the Senate threw out end-of-life counseling provisions in committee. What should be more concerning is the deals the Obama administration is brokering with the pharmaceutical lobby. Even Air America is on that.

Regards,

Karen

Karen Luttrell said...

"paring knife" - It's too late.

JTB said...

Maybe living wills are irrelevant for people who don't think about their mortality until it's inevitable. I think that's a bit unwise, but there's nothing anyone can do to force someone to be introspective about their mortality; all you can do is suggest that maybe that's a good idea. And that seems to be the point of "Health Care Decisions Day" up in Alaska, and the point (as I interpret it) of this section of the HR 3200 bill.

I do think it's a valid concern generally to make sure that advance directives and living wills actually do reflect the individual's own wishes. I don't know about the VA document, other than what the article you linked to says about it, but if it does in fact push people one way or another, then that is problematic. I would find it equally problematic regardless of which agenda is being covertly pushed. The "Five Wishes" document referenced in the article I have some passing familiarity with, having acquired a copy awhile back at an adult Bible class in church discussing issues of a biomedical nature.

But the question is whether HR 3200, section 1233 has the same problems as the VA document Towey refers to, and I don't see that it does. I don't think it's disingenuous to raise the issue of how important it is to make sure that people are able to express their own wishes regarding end-of-life care, but I do think it's disingenuous to insist, like McCaughey does, that this bill pushes an agenda to withhold or withdraw care.

I had heard that this section has been thrown out, but McCaughey was still making this a central point of her case that this bill is "dangerous for seniors." So it's still being used as a talking point, even if it's totally irrelevant in terms of the process. Maybe she should be talking about how the VA document is "dangerous for veterans" instead, if Towey's take on the document is accurate, but it seems to me that's another discussion.

I'm not quite getting, though, what you're arguing in the first paragraph: "Under a universal health plan, extending life as long as the patient desires will compete with efforts to manage healthcare costs. That means rationing to some extent." I get that in a general sense if everyone chose end-of-life care that included all possible medical interventions, that this would mean incurring the costs of these life-sustaining procedures. How does that connect to rationing? Is it that these priorities (life-extension versus cost-cutting) are necessarily competing, so that if cutting costs is a priority then you have to therefore push withdrawal of end-of-life care? If I'm reading this right, then it seems that the argument is "fiscal responsibility" must always conflict with life-extension, which certainly flies in the face of the general right/conservative/Republican position on these two things. And personally I'm not willing to grant that these priorities have to be in conflict.

Karen Luttrell said...

There are three ways to implement a universal healthcare system. A single-payer like Medicare which is going broke and fiscally unsustainable. Or a fee schedule like Tricare (military plan) that pays doctors less, so they have to see more patients. This impacts the quality of care and discourages people from entering an already shrinking field of primary care drs. The other is rationing. At some point, under a gov't run plan they will say,"You are too X or Y to receive more care." They are doing this in the Netherlands and have for years.

We could not have the same care under the profit-driven system we have now under a universal plan. If we did, we'd go bankrupt. It's not just healthcare. That's another thing the Dems are missing. We would have to change how we train doctors. Where docs live. The number of hospitals available. There is no bill that will get out of Congress that's not rubber stamped by the pharmaceutical and insurance industry. Heck, the House bill is an health insurance company bailout. Even Obama knows that those industries support others. We don't have one economy, but economies within economies. Countries like Great Britain, Germany, Canada or Japan could have effective healthcare, if managed correctly, but they can't get it right. The US problem is much more challenging, because of the large volume of data. We'd have to have some form of virtual medical records to sustain a program like the House is proposing, but the technology doesn't exist to manage that data. The VA and DOD can't manage to create compatibility with their current digital record systems. And there aren't enough redundancies to access and store patient records if they are compromised. Just storing and maintaining records would incur a huge cost.

People are hesitant about adding another 1 trillion to the taxpayer burden. Plus, there's little discussion about important issues like tort reform, incentivising docs to move to high demand locales, closing hospitals to reduce overhead, reforming Medicare and Medicaid and add more eligible recipients. A healthcare bill will pass, but Dems have tunnel vision in this healthcare reform debate, and it will be a mess.

JTB said...

I just don't know how to respond, Karen, because I am too aware of my ignorance with regard to economic generally. There's just a lot in what you've said that I don't know what I need to know in order to put it together logically, or, possibly, I just have some large-scale presumptions that run counter to yours that are interfering, but either way, I can't for the life of me figure out how to respond with anything substantial. Sorry. Comment FAIL. :(

Karen Luttrell said...

Jen,

Check out this article from the Atlantic. It's a constructive and critical analysis of the healthcare reform debate. He's also a Democrat. http://www.theatlantic.com/doc/200909/health-care

Karen