POLST and the next generation of the “Do Not Resuscitate” order

POLST stands for “Physician Orders for Life-Sustaining Treatment”. It is a next generation replacement for an Advanced Directive and DNR (“Do Not Resuscitate”) order. Advanced planning documents turn out to be less than useful, especially in urgent care settings, and many patients receive more aggressive care than they might want because universal, transferable physician orders are unavailable or, simply, not applicable because a patient is in a different care setting.

The POLST Form is a standardized form designed to convert wishes for life-sustaining treatments into medical orders. It was developed in Oregon, and has found its way into several states (in NY, for example, it is called MOLST, for “Medical Orders for Life-sustaining Treatment). POLST stands at the threshold of reality for the citizens of NJ in the form of Senate Bill Number 2197 (introduced July 19, 2010, sponsored by M.Teresa Ruiz, District 29, Essex and Union; and Loretta Weinberg, District 37, Bergen). The goal of this program is to “change the culture of end-of-life care.”

Companion legislation proposed by the same sponsors, Senate Number 2199, creates a NJ Advisory Council on End-of Life Care within the Department of Health and Senior Services.

The POLST legislation contains some very interesting provisions. “A healthcare professional,” it states, “shall not be subject to criminal or civil liability or to discipline… for professional misconduct for any action taken… to carry out the terms of the completed POLST Form…” However, “failure to act in accordance with the requirements” is subject to discipline.

The Commissioner of Health shall establish and operate a Statewide POLST Registry, as well as create and supervise a nine member POLST Registry Advisory Panel consisting of the Director of the Office of Emergency Medical Services, an assistant plus seven members to be appointed by the Commissioner consisting of a paramedic, hospice representative, a physician, hospital representative, nursing home representative, and two members of the general public, at least one of whom is a minority or member of an ethnic group.

The parallel bill creates another panel, this time called the “NJ Advisory Council on End-of Life Care” within the DHSS. The rationale for this creation finds itself in the Dartmouth Atlas of Health Care 2006 Study that found that more money is spent in the last six months of life in NJ than just about anywhere else in the USA. The goal of the Council would be to assure “compassionate and humane caring for patients who are terminally ill to preserve their peace and dignity.”

The Council consists of seventeen members: Commissioner of Health and Senior Services; two members from the Senate and General Assembly; 11 members to be appointed by the Governor with advice and consent who represent hospice programs, two physicians, hospital representative, nursing home representative, nursing representative, attorney, certified patient advocate, two members of the general public, one a racial minority or ethnic group representative. There are no specific recommendations for any clergy.

The stated “overriding” concern is “to promote an end-of-life care paradigm in which patients’ wishes are paramount” and provided with dignity and respect.

An act of law is potent stuff. It can spend. It can fine. It can punish and imprison. It can kill. It commands obedience. Somehow, though, one wonders, does the power of the law need to be invoked to assist acts of compassion or cultural acceptance and/or social engineering? What about medical ethics and the need to re-emphasize physicianly compassion?

Well, these proposed acts are, aside the humanitarian rhetoric, really an admission that the precedent laws of bioethics have failed. By 1999, Braddock’s study revealed that Informed Consent was poorly executed and as few as 9 percent of clinical decisions met the criteria for completeness of informed patient decision-making. And Informed Consent is perhaps the oldest of the attempts to put bioethical principles into law. Who today would denounce giving patients the information they needed to make informed decisions?

Advanced Directives may have found legal mandate, yet their promise remains unrealized. Most people do not have advanced directives, or do not use them adequately. Surveys show, for example, that chronic dialysis patients favor and support advanced directives in principle, but only 38 percent complete them.

The Patient Self-Determination Act (PSDA) “was enacted specifically because so few individual complete advance directives and because the living will plus its close relative, the durable power of attorney, were considered abject failures with respect to patient autonomy.” The PSDA was an utter failure. Indeed, one commentator suggested that the PSDA, rather than promoting autonomy for patients, actually did a disservice. It promoted the execution of uninformed and/or under-informed advance directives and thus undermined rather than protected self-determination of the patient.

Laws relative to organ donation and/or brain death continue to be contentious and frequently ill-advised. Laws regarding surrogate motherhood have been an equal disaster, both for the children as well as the parents and surrogates. Arguments over the patenting of the Human genome, or the “right to die”, or the direct-to-consumer advertising of prescription pharmaceuticals, or the comparisons of superiority of one insurance plan compared to another, or the abortion debate or the stem cell debate, etc. all bespeak the altered medical, ethical, social and legal landscape, and just how poorly we have performed in addressing these societal needs through law.

It has become common to assert that the law is good even if badly applied. It is ironic that our ability to decide for ourselves and to retain some measure of control over our own destinies now by implication requires the “infinite” wisdom of central planning, especially when once the issue was individual freedom of choice and autonomy. Ever new and more ambitious proposals are created to make the “good” idea work. Is it not time to consider tools besides the law that might better serve our ends? Or is there some reason to believe that Utopia can only be legislated into existence?

At issue is not whether or not rationing or death panels or insurance coverage or legal mandates or government interventions are needed or will succeed, but simply is it good and sensible public policy to create legalized and narrow standards? And that the execution of policy then is entrusted to committees or councils of “designated strangers”?

The likelihood for conflict of interest and the ultimate destruction of patient autonomy and with it the final vestiges of trust in the medical professions loom far greater than the promise of “compassionate end-of-life” cost savings these proposed laws are attempting to achieve.

POLST, PSDA, EOL, DNR: changing the lyrics does not alter the melody. What is left of freedom? What is left of trust?

Jeffrey Hall Dobken is an assistant clinical professor of pediatric immunology and allergy, and certified bioethicist at Weill Cornell School of Medicine in New York City.

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  • http://www.twitter.com/alicearobertson Alice

    Thank you so much for this well-informed articulate article. You helped me to see the dark spots of legislation aimed at the real cost of a human life, and the stripping away of our rights under an altruistic guise of shallow humanitarianism. The panels are a bit to Orwellian for my taste,,,,,and governments often go into totalitarianism under the false curtain of equality of man…….while
    the truth of the dark realities lurk ….and when exposed the damage is done. It seems sometimes we help the executioner make a neat noose not realizing the noose will be our own snare. Nice job Dr. Dobken…….you are the true humanitarian for taking a risk that allows us to hear a type of death march……we may find ourselves marching to someday if people don’t listen to the real lyrics.
    Hmmm…a bioethicist, writer, and a musician all wrapped in one….a type of terrifying, triage, tale teller that should transport us out of our thralldom! :)

  • Hexanchus

    I appreciate your thoughtful analysis, but disagree with your conclusions.

    IMHO, the availability of a POLST is a good thing for patients that choose to have one. It closes a couple major loopholes of the advanced directive – it applies to all health care providers, including EMS, and it puts penalties in place for those who would ignore the patient’s expressed wishes with respect to end of life care.

    The medical industry has run roughshod over the patients’ rights of autonomy and informed consent, as clearly pointed out in the study you referenced. The bioethics community has repeatedly failed in it’s efforts – how many more chances do they deserve? I believe it’s time to take the control away from them and give it to those whom it most directly effects – the patients themselves. If it takes an act of law to accomplish this, so be it.

    The POLST gives the power of self determination back to the patient, where it belongs. If a patient doesn’t want one, they don’t have to have one. They are strictly voluntary on the patient’s part – just like with an advanced directive, they only happen if the patient initiates it.

    • Jeffrey Hall Dobken

      This perspective, that creating more law to accomplish a “good” (or “right”) that has somehow been unaddressed in real life represents a majority view that is understandable and needs to be respected for progress on these thorny issues to occur. The view that autonomy will be preserved, however, by ceding it to government, is equivalent to the expectation that the division of motor vehicles will correct a name misspelled in their computer without a court order. At best naive.

      Here is an example from real life that argues against a priori legalization of end-of-life scenario: POLST for a child: a youngster with metastatic Ewing’s Sarcoma that has become resistant to therapy, but not yet in terminal stage, whose recently divorced parents are in conflict over whose parental authority should prevail (father asserts comfort care, mother doesn’t agree), adult sibling offers third opinion, maternal grandparents are for comfort care and all measures and paternal grandparents ( both physicians) feel thay must oppose all other “interested” parties because of their education and concern that volley ball is being played with the child’s welfare by other family members. Of course, the patient has no legal standing in this. Who determines the “best” pathway for this child, and the resolution of the conflict… which inevitably will have a negative outcome for everyone. The DMV? Think about it. Even a six-gilled shark should be able to see that a legal mandate cannot address these issues in this fashion or this socio-political environment.

      • Hexanchus

        Jeff,

        Certainly the interests of a young child need to be particularly protected. The scenario you pose however, is extreme, and not realistically representative of even a fractional percentage of cases where a POLST is requested.

        That said, the best interests of the child can be easily addressed and protected through an existing mechanism – the automatic appointment of a guardian ad litem, just as is done with minor children in a divorce proceeding. Older children, especially those in their mid to late teens, depending on their level of understanding of their condition, treatment options and prognosis, should be able to actively participate in or solely make these decisions for themselves. Call it a “medical emancipation”, as is commonly done with reproductive care decisions.

        I agree that it is sad that it would take an act of law to force the medical community to behave morally and ethically by respecting the patients’ constitutional right of autonomy and self determination in their own medical care, especially when it comes to end of life issues. Unfortunately, that is where we sit today. The medical/bioethics community, as evidenced by their repeated failures, has proven themselves incompetent to effectively address this issue. As I said before, it’s time to take the control out of their hands and put it back where it should have been all along – in the hands of the patients it affects. If they will not willing cede it, and it takes an act of law to wrest it from their grip, so be it.

        This is not some Orwellian plot as you have characterized it. There’s no death panel, rationing or DMV involved – only the patient and the physician. The POLST gives more autonomy to the patient, not less. Before you categorically denounce it, take a real look at the record in Oregon and other states where it is in effect – the results have been overwhelmingly positive.

        Your underlying concern seems to be the loss of “the final vestiges of trust in the medical professions”, but I can’t help but wonder if the loss of control over the physician/patient interaction isn’t part of it. If that trust has been lost, then it is a direct result of their own actions or in-actions. If you want the patient’s trust, then earn it – quit trying to control them, and treat them like intelligent partners in their own care and respect their rights of autonomy and self determination. Paternalism in medicine is dead or dying, and rightfully so. It’s high time for the medical community to realize this, bite the bullet and change accordingly.

        • http://www.twitter.com/alicearobertson Alice

          Jeff,>>>

          Hi! I am, obviously, not Jeff, but while I have your ear I do have some questions. First of all that’s a really curious posting name. I am sure you made that with great purpose……but a shark? Are you a doctor? :) I hate a love/hate relationship with doctors…so I thought I would ask out of curiosity.

          [quote] Certainly the interests of a young child need to be particularly protected. The scenario you pose however, is extreme, and not realistically representative of even a fractional percentage of cases where a POLST is requested. [end quote]

          Alice: It may be extreme, not typical, but it will and could be realistic, so when someone like Dr. Dobken sounds a trumpet one wonders if you will stand by these words if the “extreme” example was your own child or grandchild? I have had two children with cancer, so I am more of the type who wants to know what could await me (ignorance is not bliss at times like this).

          I thought one of the visions of medicine was to be prepared for the untypical…rare circumstances-?

          [begin quote] That said, the best interests of the child can be easily addressed and protected through an existing mechanism – the automatic appointment of a guardian ad litem, just as is done with minor children in a divorce proceeding. Older children, especially those in their mid to late teens, depending on their level of understanding of their condition, treatment options and prognosis, should be able to actively participate in or solely make these decisions for themselves. Call it a “medical emancipation”, as is commonly done with reproductive care decisions. [end quote]

          Alice: You make it sound so easy……so all of this will take place while a child is sick, or medicated, or through the crystal ball in admissions? I thought this action took place on those who aren’t capable of these types of decisions? Are you suggesting my teen who has cancer should make sure and be emancipated before any more procedures? Your answers don’t seem feasible in all but a few cases (which would require foresight), and you didn’t seem to think the hard cases are worth this type of red-flagging?

          [begin quote] I agree that it is sad that it would take an act of law to force the medical community to behave morally and ethically by respecting the patients’ constitutional right of autonomy and self determination in their own medical care, especially when it comes to end of life issues. Unfortunately, that is where we sit today. The medical/bioethics community, as evidenced by their repeated failures, has proven themselves incompetent to effectively address this issue. As I said before, it’s time to take the control out of their hands and put it back where it should have been all along – in the hands of the patients it affects. If they will not willing cede it, and it takes an act of law to wrest it from their grip, so be it. [end quote]

          Alice: Waxing so eloquently……..that’s a nice ideology, but the rest of your letter doesn’t seem to back that up. On the surface most people will agree with you, but if they take your entire letter in context it’s really a diatribe that encourages more government control (which as you say is often necessary, but it should be limited…..if there are other ways let’s look to those and I think this article does that. Let’s prevent situations that will take more legislation to enforce). Isn’t one of the goals of medicine prevention? That mindset should enter this debate.

          That’s an interesting summation because you seem (on the surface) to promote parental control under the guise of more government regulation……then promote teens being emancipated? You have if’ey answers to problems that can be foreseen. Your answers are on the same level as that which you condemn?

          Why are bioethicists so ineffective? Do you find no place for them at the table? Clearly, now that God is off the table they don’t have a common foundation to agree upon, which means much of it is relative. We can see this here. You and Dr. Dobken are both debating about the rights of the patient supposedly foremost, yet under a magnifying glass I find myself persuaded by Dr. Dobken.

          [begin quote] This is not some Orwellian plot as you have characterized it. There’s no death panel, rationing or DMV involved – only the patient and the physician. The POLST gives more autonomy to the patient, not less. Before you categorically denounce it, take a real look at the record in Oregon and other states where it is in effect – the results have been overwhelmingly positive. [end quote]

          Alice: You seem a bit progressive in thought? You can place a nice label on a problem, but it’s still there…..so maybe you can tell us the real purpose of these panels. Just because we don’t like the label doesn’t make the legislative answer to the problem any different. Appointed people (that’s bothersome in itself) forming a panel to discuss death is not a death panel? Can we wish it away with a dream and a prayer?

          [begin quote] Your underlying concern seems to be the loss of “the final vestiges of trust in the medical professions”, but I can’t help but wonder if the loss of control over the physician/patient interaction isn’t part of it. If that trust has been lost, then it is a direct result of their own actions or in-actions. If you want the patient’s trust, then earn it – quit trying to control them, and treat them like intelligent partners in their own care and respect their rights of autonomy and self determination. Paternalism in medicine is dead or dying, and rightfully so. It’s high time for the medical community to realize this, bite the bullet and change accordingly. [end quote]

          Alice: I like the above paragraph. You are advocating for the patient, which makes the rest of your letter even more interesting.

          • Hexanchus

            Alice,

            To answer your questions…

            One of my long term hobbies is photographing and observing marine creatures in their natural environment, and sharks in particular. To date I’ve been fortunate enough to be able to closely observe over 2 dozen species of shark. Hexanchus, are a genus of deepwater sharks in the family Hexanchidae. They are considered the most primitive of all the sharks, because their skeletons resemble those of ancient extinct forms, with few modern adaptations. I have had the privilege of encountering and observing these magnificent creatures in their natural environment on several occasions, and they are truly awe inspiring.

            No I’m not an MD. My undergraduate degree is in engineering. Additionally I have two post-graduate degrees also in engineering and one in physics.

            Now a question for you – have you actually read the two bills that Dr. Dobken referenced? If not, you might want to go to the NJ legislative site and do so. Read them carefully without trying to read ant hidden meaning into them – they are very straightforward. Do I agree with everything in them? No, I don’t, 2199 in particular, but it appears they are trying to do this for the right reasons. If you read the justification in 2199, it’s pretty clear that they suspect terminally ill patients are being way over treated compared with patients in the rest of the country. Call me cynical, and this is strictly my opinion, but follow the money. Is it possible that the medical industry is milking every possible last insurance dollar they can out of these patients before they die, whether it benefits the patient or not? I think that’s a question that needs to be asked.

            In regard to your comments on my previous post, please don’t try to paraphrase what I said and twist the meaning in the process. What I said is clear, consistent and unambiguous. Nothing in my post advocates more government control – quite the contrary. What I do advocate is giving the control back to the patients, where it rightfully belongs.

            To summarize.:
            1. The patients’ rights of autonomy and self determination with respect to making decisions about their health care, including end of life care decisions must take precedence, and must be respected and complied with by the medical community.
            2. The best interests of a younger child can be easily addressed and protected through an existing mechanism – the automatic appointment of a guardian ad litem, just as is done with minor children in a divorce proceeding.
            3. Older children, especially those in their mid to late teens, depending on their level of understanding of their condition, treatment options and prognosis, should be able to actively participate in decisions regarding their care, or in some cases make these decisions for themselves.
            4. The POLST is a proven mechanism with an outstanding record in helping patients regain control of their medical care decisions. Participation is strictly voluntary on the part of the patient, and they can modify their preferences at any time.

            The only real downsides are to the medical community – it takes away much of their vaunted control and forces them to respect the wishes of the patient.

  • http://Www.Twitter.com/alicearobertson Alice

    I am still in the deciphering stage of this healthcare bill…..not in the mirage stage many are in….more the inquisitive stage. After reading your post I couldn’t help pondering about a few things, The first question I pondered about was……if this is so helpful to the patent why the exoneration from criminal charges? I am a mom, who loves and cares for her children more than any doctor, or unfamiliar person on an appointed panel,,,,how come I can’t get that type of immunity from the law? How can people……mere humans…..make a decision about my life and leave the family outside of some type of supposed experts at execution of legislation and life panel? Just pondering aloud…..because advocating this seems to a real slippery slope.

    This seems a bit to carte blanchish? Although, I would love that type of immunity in my life…..i seriously do not think it is necessary or desirous that those dealing with the lives of others have that type of unrestricted power with no accountability.

    I keep thinking….well hoping….I am misunderstanding what seems like a type of police state in medicine under the guise of helping me….if my inclinations are wrong….then yippee!….but if my assumptions after reading this revealing article are right……..well…..Houston….we got a problem….and it is bigger than death panels….it is with the people listening to the Pied Piper unquestioningly……I hope I am misunderstanding….please help me find the truth if I am wrong. I am listening….and hope it is not a tender alluring melody that puts me in a coma like state…….where I lack discernment.

  • http://www.twitter.com/alicearobertson Alice

    Hi! I like to read Chuck Colson, and he has some good input on this topic. I realize few have the time it takes to study these important topics, but one never really knows who will stumble upon a thread like this while studying where the current administration wants to go with this agenda. Consider we now have Dr. Berwick and his love affair with the British national health care system, I thought this was pretty interesting for those who claim there are no death panels (I am still wondering what the media will call them? Reuters doesn’t want their journalists using the word “terrorist” for those who use terror to get their own way, so what is the politically correct term for “death panel”?). I placed a few excerpts I would love to see addressed here, and the reason they will not be duplicated if we don’t take heed. I really am sincere in my asking.

    http://www.breakpoint.org/commentaries/12636-not-in-the-national-interest
    You don’t have to look far to see that their mistrust is well founded. Check out the British press virtually any day online, and you will find horror story after horror story about what can happen when the power of life and death is handed over to a government bureaucracy.

    I’ve spoken before about Britain’s National Institute for Health and Clinical Excellence (and I’ve also pointed out the sinister irony of that organization’s acronym, NICE, which was the center of evil in C.S. Lewis’s famous novel That Hideous Strength). NICE and similar agencies are setting health-care guidelines for the British National Health Service that are leading directly to a devaluing of human life. *snip* more at the above URL

    more: Just this month, Rosemary Munkenbeck told the Daily Telegraph that doctors withdrew fluids and drugs from her father elderly father, Eric Troake, after he suffered a stroke. He appears to have been treated according to a National Health Service “pathway scheme” for dying patients—even though it was not clear that he was actually dying, and despite having said that he wanted to live to be 100 if he could. *snip*

    more: Though Jayden, delivered by a midwife, was breathing on his own and moving his limbs, doctors refused to treat or even see him. Capewell says she said to one doctor, “You have got to help,” and he responded, “No, we don’t.”

    Some lives may indeed be impossible to save. But what we have here is a government bureaucracy that has the power to determine—as a matter of policy—not to save lives that could be saved. In essence, determining whose life is worth the expense.

  • http://www.twitter.com/alicearobertson Alice

    Hi! I am typing on my Droid. I enjoyed reading about your hobbies…..of course, I could not help myself in relating to your shark studies…..you run into some real sharks surfing the web….*grin* So…you are not an MD….I lteach literature, so I like analysis….I blog about literature helping me through my current crisis of cancer….I. feel like I am caught in a bad plot. Can I ask if you are an attorney? I did read and enjoyed your letter, but was still unclear about several aspects. I ask if you are an attorney because engineering was mentioned as secondary, and you seem to be a bit passionate about this. I will share that I volunteer at a Judeo-Christian think tank…and we not only find the repercussions of the death panels scary…we thinl it’s bloody-well terrifying *grin* I lived in the UK and have seen the fruitiion of this mindset at play…..putting a cost on human life by a panel with no personal vested interest should cause alarm bells to go off…..and to label it as a gift with such a nice wrapping…and playing kill the messenger when someone sets off alarm bells is clearly disingenuous on behalf of the medical profession (which I am not too happy with at the moment because an arrogant doctor at Cleveland Clinic refused to listen to my motherly pleas and reassured me all was well while cancer spread through my daughter’s lymph nodes).

    I did see a copy of the bill, and read enough to see they can kill someone with no repercussions. I will admit I did not study it from a legal analysis…but a motherly analysis.

    More when I find a real keyboard…..

  • http://www.twitter.com/alicearobertson Alice

    Hi! I apologize for my messy posts….still on my Droid so you will need those deciphering skills. I am curious though….I have libertarian leanings and think government regulation should be our last choice. Where do you stand on tis aspect?

    So, you would not label this on an Orwellian level? Hmmm…..how about Lowry’s The Giver where death panels give injections to failure to thrive babies? When the author won her coveted book awards for her writing some of her interviews made us asutely aware of the warning signs of future games. Games that are played by disengaged people who do not see that you can win a battle and lose the war.

    Okay…you have my attention….I am curious……I will say reading about your fascination with sharks was interesting…hmmmm……your posting name…..a metaphor?

    I, also, found your use of the cautionary word “twist” of interest….could you share in more detail about this? Do you have a better name for the death panels? Do you believe in immunity remaining in the bill?

  • Alice

    Grrrr….this Droid has a mind of it’s own….I did not finish the previous post. It seems to me you think the end justifies the means. More like a bait-and-switch scheme? As if some major good means the minors lose out? How can we support legislation that thinks end-of-life care is too costly and puts a price on what they deem worthy? This seems more like a Pandora’s Box than something I could ever support.

    Do you have a problem with an appointed panel? In my state part of the school board is appointed and it’s a right mess of political agendas.

  • http://www.twitter.com/alicearobertson Alice

    Okay, I finally have a monitor I can see and a keyboard. There is a bioethicist I like and he wrote a book about death panels, and bioethicists who decide a human beings fate behind closed doors without fear of repercussions (of course, that doesn’t mean what it seems to if you believe in any type of judgment seat at death….but that’s for another day….but….even for those who disagree if you are wrong…um…dum de dum dum…….*grin*, but if I am wrong all I lost was some time and effort).

    Okay, I’ll get serious and keep it short…..an excerpt from Wesley Smith’s book. I have to ask what you would do in this case and how POLST would have been an asset at the time of diagnosis of this child? Sure it may not be typical…..but isn’t that what we are discussing? People playing God? What if a death panel had chosen this child as too expensive to keep alive? I guess we wouldn’t know because dead people tell no tales…….

    quote: Illustrating the danger, in Culture of Death, I recounted the Baby Ryan case, in which doctors wanted to unilaterally refuse dialysis based on their view that the baby had zero chance of surviving kidney failure. They were wrong. The boy was eventually weaned off dialysis and lived for several years, during which time he was a happy child, the apple of his parents’ eyes [end quote]

  • http://Www.Twitter.com/alicearobertson Alice

    Your response shows you have thought about this piece of legislation, and did respond openly on some issues and points.  I am intrigued enough to try to walk through this.  I hope you enjoy literary analysis?  

    Since I like literature (and hope you do too) I wanted to share some short excerpts (one from the guy who stole my heart…he doesn’t know about it…yet…he will though *grin*….oh how I love CS Lewis,,,,,pure magic…oops sorry…got off track….hard to think when your heart is fluttering:). ). I think these excerpts are quite good and so appropriate to this discussion….to think of how long ago they were wrote, but the knowledge that man would want to create and kill was covered well in Frankenstein.

    Tolkien wrote in The Two Towers about the traitor Saruman torturing the noble wizard Gandalf, “What,” the evil wizard asks Gandalf, “is the greatest power?”
    “Life,” Gandalf replies.
    “You fool,” says Saruman.  “Life can be destroyed.  Did I teach you nothing?”
    Trying again, Gandalf says, “Creation,”
    “Yes,” answers Saruman, “the power to create life.”

    Such truth in fiction….but let us go to the great apologist Lewis…in The Abolition of Man he offers a prophetic warning;  “If any one age really attains, by eugenics and scientific education, the power to make it’s descendants what it pleases, all men who live after are the patients of that power,” slaves to the “dead hand of the great planners and conditioners.”.  

    Doesn’t mankind have a duty to care for others beyond the tip of our noses?  If life is all about me, then what happens when it’s my own name on the table, and my name being discussed by a panel of people who do not know me?  Is the family irrelevant?  Lives expendable over money?  That’s of great interest to me because it is the very foundation of the supporters of the healthcare bill.  

    So which is it?  Only some lives are worth the cost to the taxpayers, or all lives?  And where will this lead?  Down Syndrome babies are already an endangered species that is unprotected because a panel of judges deemed babies in the womb to have no rights……a panel at any given time can legislate morality…and so it is with bioethicists (this is why I had hoped you would expound on your original statement).

    What foundation do we base anything on when we resort to appointees?  I have problems with the Supreme Court going beyond what I believe their original powers were to be, but that’s for another day.   

    Basically, I am asking what are the Constitutional rights of sick people, and you are going to respond that POLST protects, while I will respond it is too far reaching, and gives too much power to a panel, and too little power to the weak.  Fair?  Contitutional?  I don’t think so…and again where will this lead?

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