Wednesday, August 12, 2009

Comment Rescue: On rational people and thoughts that require serpentine logic

Recently I wrote a post on end-of-life counseling under proposed health care revisions in response to this rather bizarre post at Resolute Obfuscation. [By the way, at two days and counting, Hand-Reared Boy--an homage to Brian Aldiss--still can't see his way clear to take my comment out of moderation.]

I cited research collated and posted at Medical Futility Blog indicating that not only was such counseling effective, but was desired by patients.

Hube responded by agreeing with me on the benefits of the counseling, but arguing that financial incentives taint the process:

But even some Dems are worried about the financial incentives in that section.

And while I concur about your analysis of "end-of-life" consultations, I must say I am flummoxed by your seeming non-chalant attitude that the government would be involved in such ... and also considering some of the characters in Obama's admin.


mike w. seconds that opinion:

I'm with Hube. I don't like the financial incentives for doctors that's attached to the end of life counseling part of the bill.

The government need not be involved in that at all, as it's something that should be purely between the physician & patient.

That said, the more vocal opponents of Obamacare are turning this into something it's not. It's no evil government plot to kill off the elderly.

As a comparison, should doctors be given a financial incentive to insist on abortions? Of course not. I don't want the government giving financial incentives that pressure physicians into particular methods of care.


First (and I mean this sincerely) kudos to Hube and mike w. for (1) recognizing the value of such counseling and (2) focusing not on anybody's intention to kill granny, but on the question of financial incentives that might interfere with, let us say, an unbiased consultation.

With all due respect, I dismiss mike w.'s comparison to giving a financial incentive to insist on abortions, because the insistence on end-of-life counseling does not mandate a particular outcome. If you want heroic measures taken at your bedside no matter whether you are brain-dead or not, you can so specify in a living will. If you want your crazy Aunt Bertha empowered to make all your medical decisions, you can do that. If you decide, in advance [as my own parents did a few years back] to specify the conditions under which you want them to pull the plug, you can do that as well.

The fear seems to come in with the idea that the doctors doing the consultation, will have a subtle pressure placed upon them to euthanize dear old granny, as Hand-Reared Boy fears:

Please note the well to do with educated kids will be there to intervene but the poor and uneducated will be told it’s all good and the plug will get pulled.


There are two research-based responses to this, neither of which will make the Boy happy.

1) More of the futile medical treatment prescribed for aged, comatose, or vegetative patients comes at the behest of doctors and not patients. In other words, research suggests that physicians are more conservative about end-of-life decisions than their patients.

2) The second is that most people prefer to have the opinion of their physician in this matter, and that persuasion is not necessarily a dirty word. Again, Medical Futility:

Wesley Smith wrote yesterday that "[t]he Medicare “mandatory counseling” controversy in the Obamacare debate laid bare a realistic fear that compensated counseling under Medicare could easily become subtle (or not so subtle) persuasion to refuse treatment." He goes on to explain why that would be dangerous.

But there is nothing wrong with "persuasion." Tne Encyclopedia Brttannica defines "persuasion" as

the process by which a person’s attitudes or behaviour are, without duress, influenced by communications from other people. . . . The communication first is presented; the person pays attention to it and comprehends its contents (including the basic conclusion being urged and perhaps also the evidence offered in its support). . . . similarities between education and persuasion. They hold that persuasion closely resembles the teaching of new information through informative communication.


The history of physician-patient communication confirms the acceptability of persuasion. Physicians used to just paternalistically keep patients out of the decision making process. They later swerved to the other end of the continuum, abandoning patients to their autonomy. Carl Schneider and others have carefully reviewed the psychological and anthropological literature. Patients want guidance from their physicians. Thus, the dominant model today is a collaborative one. Physicians can and should share (and even defend) their opinion as to the best course of action, offering evidence and reasons (i.e. be persuasive).

Now, perhaps Wesley Smith is concerned about physician manipulation, coercion, or deception. I too fear these things. But there is no evidence that any of it would be expanded or acceletated by paying for advance care planning.


Notice that Dr Pope acknowledges the realistic fear being voiced by critics, but then points out that those critics are ignoring evidence regarding how patients and doctors make decisions together.

Of course there is potential for abuse. There is potential for abuse today, at any time that your physician decides that you don't need Test A or Medication B, because in her opinion your condition does not merit it. Your physician could be secretly plotting your death or have accepted capitation benefits from AETNA that pay her not to prescribe too much treatment.

And a government that allowed the involuntary sterilization of over 3,400 Native American women in the 1970s cannot be trusted too far.

All options, however, entail risk. There are people today whose families go through great grief and horrible times because no one had the foresight to make some early decisions. Who advocates for them?

1 comment:

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