Health care reform: The uncivil war dividing America

The following is part of a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

The unfettered debate about ideas that characterizes the democratic process in the United States operates best when there is a truthful presentation of the issues, and when the process is civil and respectful. Unfortunately, the debate about health care reform has evolved to the point that it fulfills neither of those criteria. It is legitimate for concerned parties to disagree when considering the costs of health care reform and the potential paths for financing any reform initiatives. But when facts about reform proposals are distorted beyond recognition in an attempt to fuel civil unrest, and when that unrest translates to unruly disruption of town hall meetings, then reasoned debate has transformed itself into an uncivil war.

The idea that the House bill, HR 3200, is proposing “death panels” is perhaps the most egregious misrepresentation of the reform proposal, but it is certainly not the only one. Fortunately, the media are now presenting more coverage to reveal the truth – that the bill proposes payment to health care providers for the voluntary discussion of advance directives and end-of-life issues. Sadly, however, just as the gross distortion of this proposal has become better known, the uncivil war that erupted around it may ultimately result in its elimination. This would be most unfortunate, as it is a rational proposal that is specifically intended to put an informed decision-making process about their care directly in the hands of patients, exactly where it belongs.

As someone who has practiced Pulmonary and Critical Care Medicine for many years, I have repeatedly seen from more than one perspective the importance of physicians and patients dealing with such issues. For my outpatients who are not yet critically ill but who have or are likely to develop end-stage lung disease, it is important that they understand the management options in the event of deterioration or an acute event. Advance planning allows physicians and other healthcare providers to act upon patients’ wishes at a time when they may not be able to participate in the decision-making process.

On the other hand, for my inpatients in the critical care unit who are not previously known to me and who are too ill to participate in the decision-making process, I have worked with families to best develop an understanding of what the patient would likely have expressed if he or she could have participated in these life-altering medical decisions. Trying to guess a patient’s desires, even with family input, can never compare favorably with an advance discussion between physician and patient that facilitates a reciprocal understanding of the medical issues and the patient’s wishes.

Might such discussions lead to a patient’s choosing in advance to forgo some treatment options? Indeed they might. But patients should be the ones to make these decisions – not their physicians, not even their families, and certainly not insurers or the federal government. Encouraging physicians and patients to discuss such sensitive issues encourages rather than compromises patient autonomy. This is the laudable goal that HR 3200 proposes.

If legislators decide to remove this proposal from HR 3200, the American public will have experienced an unfortunate and unnecessary casualty from this uncivil war. Just as patients need to be informed and educated with truthful facts about end-of-life care and decisions they may ultimately face, the American public deserves to be informed and educated about provisions such as the one discussed here before condemning those provisions to a premature, unnecessary, and avoidable death.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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